This Week in the ASAM Weekly

Our news stories this week show how there’s usually another layer to consider with addiction and government. California has a history of counterculture movements but it's the modern-day focus on wellness that may actually be leading the state toward decriminalizing psychedelics (Los Angeles Times). This could be a positive step but needs to be built on a framework of prevention. The Biden administration announced almost $450 million going towards addiction treatments and prevention (UPI) which is welcomed news but we need to build infrastructure that will be sustainable beyond the opioid crisis. An article from the NY Times reveals a dynamic between governments and cartels in Mexico that has more to do with funding and protection than it does with corruption -- or was it the other way around?

Washington state was early to cannabis legalization so it may or may not be surprising that cannabis use disorder is actually quite common (21%) in primary care patients who use cannabis in the state (JAMA Network Open). But what’s even more interesting is how much we are learning about the endocannabinoid system during this era of legalization. For example, endogenous cannabinoids can regulate stress in a way that affects motivational processes in addiction reward (PNAS) as well as alcohol consumption (Translational Psychiatry).

A study from Vancouver demonstrates how population-level testing of opioid samples could act as an early warning system for overdose risks and potentially save lives (AJPM). Communities also need tools to rapidly diagnose OUD and StUD; the Rapid Opioid Use Disorder Assessment (ROUDA) and the Rapid Stimulant Use Disorder Assessment (RSUDA) could help both clinicians and non-clinicians alike (Psychiatric Research and Clinical Practice). These assessments also remind us that although substance use is not a course specifier for remission (DSM-5), its utility in diagnostic tools and research outcomes continues.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD

Lead

Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal 🔓

JAMA Network Open

This cross-sectional study investigated the prevalence of cannabis use disorder (CUD) among primary care patients in states with legal recreational cannabis. Patients were asked to report medical use, nonmedical use, or both, with 42.4% reporting medical use only, 25.1% nonmedical use only, and 32.5% reporting both. The prevalence of any CUD was 21.3%; for moderate to severe CUD prevalence was 6.5% overall, with 1.3% reporting medical use, 7.2% nonmedical use, and 7.5% reporting both. Those reporting medical use only tended to be older, female, and retired. Those reporting nonmedical use or both were more likely to disclose withdrawal; use in hazardous situations; use despite persistent or recurrent social or interpersonal problems; important social, occupational, or recreational activities given up or reduced; and use despite persistent or recurrent social or interpersonal problems. Hence, screening for CUD among patients who use cannabis is paramount.

Research and Science

Synaptic and cellular endocannabinoid signaling mechanisms regulate stress-induced plasticity of nucleus accumbens somatostatin neurons

PNAS

How stress affects neuronal plasticity within brain reward circuits is important to understand given the link between stress and mood disorders and addiction. While endogenous cannabinoids (eCBs) are well known to regulate synaptic plasticity onto NAc medium spiny neurons and modulate nucleus accumbens (NAc) function at the behavioral level, how eCBs regulate NAc interneuron function is less well understood. This study shows that endogenous cannabinoids regulate the balance of excitatory drive to the nucleus accumbens in mice and are required for stress to shift excitatory drive to this key reward center. These cannabinoid-mediated shifts in balance of excitatory drive could reveal how stress affects motivational processes and provide insight into the neural basis of cannabis reward.

Validation of Two Diagnostic Assessments for Opioid and Stimulant Use Disorder for Use by Non‐Clinicians 🔓

Psychiatric Research and Clinical Practice

This cross-sectional study tested the validity of two DSM-5 diagnostic assessment tools for opioid use disorder and stimulant use disorder by non-clinicians. The study updates the Rapid Opioid Dependence Screen (RODS) to the Rapid Opioid Use Disorder Assessment (ROUDA) and includes fentanyl. The Rapid Stimulant Use Disorder Assessment (RSUDA) was also tested. The ROUDA demonstrated a sensitivity of 82.5% (95% CI) and a specificity of 100% (95% CI). Likewise, the RSUDA demonstrated similarly high sensitivity. Non-clinician diagnosis of these disorders affords an opportunity for rapid education, treatment, and implementation of harm reduction measures in community settings.

Fentanyl concentration in drug checking samples and risk of overdose death in Vancouver, Canada

American Journal of Preventive Medicine

Fentanyl and its analogs are the known major drivers of the opioid overdose epidemic in the last few years and in response community drug checking services have expanded, which allow persons who use drugs to test their supply. These programs test for the presence and concentration of fentanyl. Utilizing the fentanyl concentration data from these services in Vancouver, Canada, the authors found a strong association between median monthly fentanyl concentration and illicit drug toxicity death rates between January 2019 and October 2020. There was a notable increase in both the fentanyl concentration and overdose death rate starting in March 2020. The authors suggest that data from these types of services can be used as a tool to monitor evolving drug supply and fentanyl concentrations which can inform real-time public health responses.

N-oleoyl glycine and N-oleoyl alanine attenuate alcohol self-administration and preference in mice 🔓

Translational Psychiatry

It is hypothesized that drug-induced elevation in endocannabinoids (eCBs) and/or eCB-like molecules (eCB-Ls) may represent a protective mechanism against drug insult, and boosting their levels exogenously may strengthen their neuroprotective effects. This study determined the involvement of the endocannabinoid system (ECS) in alcohol addiction. Systemic administration of N-oleoyl glycine (OlGly) or N-oleoyl alanine (OlAla) during intermittent alcohol consumption significantly reduced alcohol intake and preference without affecting the hedonic state. These findings suggest that the ECS negatively regulates alcohol consumption and boosting selective eCBs exogenously has beneficial effects against alcohol consumption and potentially in preventing relapse.

Learn More

Racial inequities and addiction research

Drug and Alcohol Dependence

There is a significant need for research on the racial and ethnic inequities for substance use disorders, but there are also disparities present among those who conduct the research. The authors describe some of the efforts by NIDA to address the disparities among researchers, citing several programs including Diversity Scholars Network, Summer Research Internship Programs, Diversity Supplement Awards, and other funding opportunities. While some progress has been made in the demographic trends in funding over the last decade, the absolute number of applicants among racial and ethnic minorities remains low. One significant barrier may be relatively low salaries for post-doctoral positions that may prevent persons from lower socio-economic backgrounds from entering research careers. The authors suggest grantee institutions could offer additional support to address this barrier.

Epigenetic alterations identify a confluence of genetic vulnerabilities tied to opioid overdose

Neuropsychopharmacology

Neurons were obtained from the dorsolateral prefrontal cortex of 51 opioid overdose cases and 51 sudden death controls and studied for epigenetic changes. While the specific epigenetic changes varied in the overdose cases, they all converged on 5 genes known to be linked to OUD. The authors state that these studies increase understanding of the role of genetic influences in opioid overdose.

Preliminary Evidence of the Association between Time on Buprenorphine and Cognitive Performance among Individuals with Opioid Use Disorder Maintained on Buprenorphine: A Pilot Study 🔓

International Journal of Environmental Research and Public Health

Participants (n=16) had been on buprenorphine maintenance treatment (BMT) for at least 30 days and had used an illicit drug in the past 30 days and were compared to matched healthy controls (n=23). The cognitive tests assessed response inhibition and attention by showing participants words, colors, and letters on a screen and asking participants to respond when specific patterns appeared. The BMT participants had more errors and slower reaction times than the controls. The BMT participants had an average of 315 days on buprenorphine and the length of time on buprenorphine was associated with fewer errors and faster reaction times. There was no correlation between illicit drug use or craving and errors or reaction time.

In The News