The ASAM Weekly for April 2nd, 2025

This Week in the ASAM Weekly

Did you know there are medical marvels living amongst us with the ability to drink lots of alcohol without experiencing a hangover? Known as “hangover resistants,” these genetic mutants represent about 25% of study populations, but for some reason the government isn’t funding the research needed to protect us from them (New York Times). If you think this is some kind of conspiracy theory, it’s not. It’s an April Fools’ Day attempt to get your attention.

Now, on to the more serious side of the news:

Legal advocacy is coming to an emergency department (ED) near you. The Emergency Medical Treatment and Labor Act (EMTALA), Affordable Care Act (ACA), Title VI, and the Americans with Disabilities Act (ADA) come together in a well-crafted commentary about the legal pitfalls of not treating OUD in the ED (Journal of Addiction Medicine). But if you think this is only about OUD in the ED, you might be missing something.

A study combining some of the best minds from NIDA, SAMHSA, and the CDC found that about 1 in 4 adults using prescription stimulants engaged in misuse, and about 10% met the criteria for prescription stimulant use disorder. An important takeaway is that although we’ve seen a jump in prescribing rates, this has not been paired with any clinical practice guidelines for adult ADHD or increased training in diagnosis and treatment (JAMA Psychiatry).

Urine drug tests, Child Protective Services, and racial bias can be a harmful mix. A recent quality improvement study addressed this by removing isolated marijuana use (and lack of prenatal care) as a reason for ordering drug tests during pregnancy (JAMA Network Open). The results are positive, but the associated editorial makes an important point: it's also about weighing the harms of prenatal cannabis use vs. breaking up families.

If you hadn’t heard, America is in the midst of an overdose and mental health crisis, yet funding cuts are coming for the agencies that protect us. Health and Human Services announced a reduction of over 10,000 full-time employees (HHS) while SAMHSA might see their workforce cut in half (STAT) — all in the name of making Americans healthy again. 

These stories are sure to grab your attention — even without the need of an April Fools’ Day gimmick from the ASAM Weekly.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

Lead Story 

Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years 

JAMA Psychiatry

This study examined the prevalence of prescription stimulant use, prescription stimulant misuse, and prescription stimulant use disorder (PSUD) among adults aged 18 to 64 years in the US. Researchers found that 25.3% of adults in the study reported misuse, and 9.0% had PSUD. Among those with PSUD, 72.9% solely used their own prescribed stimulants, 87.1% used amphetamines, 42.5% reported no misuse, and 63.6% had mild PSUD. The prevalence of misuse was 3.1 times higher and the prevalence of PSUD was 2.2 times higher among those using prescription amphetamines than among those using methylphenidate. Regardless of prescription stimulant misuse status, screening for and treating PSUD is needed for US adults aged 18 to 64 years using prescription stimulants, especially those receiving prescription amphetamines. 

Research and Science 

Racial Equity in Urine Drug Screening Policies in Labor and Delivery 🔓 

JAMA Network Open

This quality improvement study of 9,396 pregnant patients assessed the association of removing isolated cannabis use and limited prenatal care as approved order indications for urine drug screening with racial parity in urine drug screening and reporting to child protective services in a hospital labor and delivery unit. Updating the urine drug screening policy was associated with a significant reduction in racial disparities in testing and child welfare reports, with no change in balancing measures. These findings suggest that an updated labor and delivery urine drug screening policy combined with clinical decision support may reduce racial bias in urine drug screening and reporting to child protective services without impacting the identification of clinically meaningful substance use.

Split-dosing of Methadone During Pregnancy and Postpartum Period: A Systematic Review of Outcomes 🔓

Journal of Addiction Medicine

The effects of methadone during pregnancy are reduced by changes in GI motility, plasma volume, renal clearance, and drug metabolism. For this systematic review, researchers reviewed 8 articles about splitting the daily methadone dose. A case study of a patient with a twin pregnancy in the third trimester who experienced withdrawal 12 hours after her methadone dose found the methadone half-life to be 8.1 hours compared to the average half-life of 24 hours. Another study found ultrarapid metabolism in 9% of patients during the first, 44% in the second, and 31% in the third trimester. Fetal movement, respiration, and heart rate variability were reduced after a single daily methadone dose but not when the dose was split. Patients receiving split dosing had improved adherence to urine screening and fewer cocaine-positive screens. Split dosing did not affect gestational age at delivery, birth weight, days in hospital, or frequency of neonatal abstinence syndrome. The authors concluded that split dosing should be the standard of care. 

Myocardial Infarction and Cardiovascular Risks Associated with Cannabis Use: A Multicenter Retrospective Study 🔓

Journal of the American College of Cardiology: Advances

Utilizing data from the TriNetX health research network, researchers investigated the long-term cardiovascular effects of cannabis use in relatively healthy adults aged 50 or younger. Focusing on adults without significant comorbidities, they compared cannabis users (diagnosed with cannabis use) to non-users and found that cannabis use was associated with increased risks for adverse cardiovascular events, including myocardial infarction (MI), ischemic stroke, major adverse cardiovascular events (MACE), heart failure (HF), and all-cause mortality. Specifically, cannabis users had a higher risk for MI, ischemic stroke, and other cardiovascular issues, even when traditional risk factors like smoking or pre-existing conditions were not present. Over a 5-year period, the cannabis user group showed significantly lower survival probabilities compared to non-users. 

High-Potency Cannabis Use and Health: A Systematic Review of Observational and Experimental Studies 

The American Journal of Psychiatry

The concentration of delta-9-tetrahydrocannabinol (THC) in cannabis has been increasing for several years, but little is known about the potential impact on health outcomes. Examining 42 articles of mostly cross-sectional studies, researchers conducted a systematic review to assess the potential impact of high-potency cannabis. The outcomes included in the studies were related to mental health, other substance use, and “problematic” cannabis use. Overall, the findings were mixed with generally low certainty about findings, except for “problem” cannabis use which was consistently associated with high-potency cannabis. The authors highlight the very limited data on high-potency cannabis and health outcomes and the need for prospective studies to address this knowledge gap, including other physical health and medical outcomes.  

Learn More 

Civil Rights Laws for People With Opioid Use Disorder in the Emergency Department 🔓 

Journal of Addiction Medicine 

The authors of this commentary call for routine initiation of medication for opioid use disorder (MOUD) for patients treated in the emergency department (ED). Regulatory barriers have been reduced: buprenorphine no longer requires an X-waiver, and methadone can be initiated in the hospital or ED, and patients discharged with up to 3 days of methadone. The failure to initiate MOUD in the ED could violate several civil rights laws. The Emergency Medical Treatment and Labor Act requires the ED to provide patients with treatment to stabilize medical conditions. The Americans with Disabilities Act includes OUD as a disability and may be violated by treating an overdose without treating the OUD. The Civil Rights Act could be violated if MOUD is not offered equally to all races. Concern about violating these laws should motivate hospital systems to implement routine initiation of MOUD. 

Pre-Arrest Diversion-To-Treatment for Adults with Substance Use Disorder: Health Outcomes and Predictors of Program Completion 🔓 

Justice Evaluation Journal 

In this study, researchers evaluated the Madison Addiction Recovery Initiative (MARI), a pre-arrest diversion program. Persons who committed non-violent drug use-related crimes were offered referral to the program in lieu of arrest; the initial charges were then “voided” at the completion of the 6-month program. The study found that completion of the program was associated with a decrease in depression, anxiety, and addiction severity scores and increased treatment with medication for opioid use disorder (MOUD). Predictors of program completion included the following: currently being in treatment, fewer prior incarcerations, shorter lifetime sobriety, higher depression, and lower anxiety scores. The authors note the study findings support pre-arrest diversion programs as they may improve mental health and substance use disorder outcomes. 

Tackling gambling harm requires a public health approach

BMJ

The authors of this editorial discuss recent guidelines from the National Institute for Health Care Excellence in the UK that recommend universal screening for gambling. However, they note there is no good evidence for this approach and instead focus on individuals. The framework around gambling is that of responsible gambling, which shifts accountability to the individual and obfuscates the need for a comprehensive public health approach, including regulatory interventions, such as advertising restrictions and campaigns to denormalize gambling. The authors suggest that a focus on the individual is only a partial response and is insufficient to address the issue. 

In The News 

The People Who Never Get Hangovers 

The New York Times

HHS Announces Transformation to Make America Healthy Again 🔓

US Department of Health and Human Services

Don’t cut substance abuse disorder, mental health funding 🔓

STAT

How The Mainstream View Alcohol And Marijuana 🔓

The Mercury News 

Purdue Pharma files new bankruptcy plan for $7.4 billion opioid settlement 🔓

Reuters

Philip Morris' heated tobacco device IQOS goes on sale in Texas 🔓

Reuters