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The ASAM Weekly for March 19th, 2024

This Week in the ASAM Weekly

THE ASAM CRITERIA®, FOURTH EDITION

Kenneth Minkoff, MD, is a board-certified addiction psychiatrist and community psychiatrist who is vice president and chief operating officer of ZiaPartners, Inc. in Tucson, AZ. Dr. Minkoff contributed to the “Co-occurring Writing Committee” for The ASAM Criteria, 4th Edition.

A radical advance in integration of co-occurring mental health care within the addiction system

As an addiction psychiatrist and community psychiatrist, I have worked on improving integrated systems and services for 40 years. Most recently, I helped to develop the updated standards in the 4th Edition of The ASAM Criteria that encourage all addiction treatment programs to be co-occurring capable, at minimum. (See Chapter 12: Integrating Care for Co-occurring Mental Health Conditions.)

I want you to be inspired and excited about the opportunity for everyone in the addiction field to learn how to be more successful, and have more fun, working with individuals with co-occurring mental health (MH) needs, who are the expectation (not the exception) among the people we serve.

Consider the ASAM Criteria 4th Edition’s definition of “co-occurring condition” (slightly paraphrased): “Any combination of any SUD or addictive condition and any mental health condition (including trauma), whether or not they have been formally diagnosed.” (p. 320).

Considering this definition, does your program routinely serve people with co-occurring conditions? The answer is likely a resounding “Yes”.

Read the full editorial here.

 

Lead Story

Adolescent Δ8-THC and Marijuana Use in the US ðŸ”“

JAMA 

D8-THC is synthesized from legal hemp plants (with low D9-THC) and has intoxicating effects similar to D9-THC. D8-THC is available in smoking, vaping, and edible products and is marketed as federally legal. To investigate the extent of D8-THC use by adolescents, data were extracted from the 2023 Monitoring the Future study in which a random selection of 12th grade students were asked about D8-THC use (n=2186). Prevalence of D8-THC use over the past 12 months was 11.4%, and for marijuana use was 30.4%. D8-THC use was lower in western states (5%) than southern states (14.4%), states where D8-THC was regulated (5.7% v. 14.4%), and states where marijuana was legal (8.0% v. 14.0%). The authors conclude that D8-THC use among adolescents is significant and deserves further attention.

Research and Science

Co-occurrence of Mental Illness and Substance Use among US Pregnant Individuals, 2012-2021 ðŸ”“

Psychiatry Research

This study examines substance use (tobacco, alcohol, and marijuana) among pregnant individuals with mental illness. Using a national representative sample of pregnant individuals derived from 2012 to 2021 National Survey of Drug Use and Health data, researchers found that pregnant individuals with greater severity of mental illness were more likely to engage in substance use. Evidence-based educational, screening, and treatment services, and public policy changes are warranted to mitigate the harmful health outcomes of substance use among US pregnant individuals with mental illness.

Serving Alcohol to an “Obviously Intoxicated” Patron ðŸ”“

Journal of Studies on Alcohol and Drugs 

This study investigated how often alcohol service was refused to an “obviously intoxicated” person. A random sample of 60 outlets (bars or restaurants) was selected from a list of outlets in the San Francisco Bay Area with an on-premises license. Young adults were trained to exhibit signs of intoxication (slurred speech, stumbling, fumbling with cash, swaying) when requesting alcohol at the outlets. Of 295 attempts, alcohol service was refused only 21% of the time. Upscale fine dining restaurants were more likely to refuse service (32.6%). Females were refused more often (30.7%) than males (7.8%). The authors note the low rate of refusal and call for better training of servers.

Community Support for Harm Reduction and Treatment of Opioid Use Disorder

Journal of Community Health

As the opioid epidemic continues, community support is needed to start and sustain community-based strategies including needle exchange, access to naloxone, and medication for opioid use disorder (MOUD). In this cross-sectional online survey, the authors evaluated beliefs associated with support for these interventions. Overall, they found significantly more support for MOUD than for naloxone or needle exchange programs. One’s own stigmatizing beliefs were associated with less support for the programs, while normative beliefs that others supported the program were associated with increased support. Interestingly, the perceived stigma of a program by others was associated with increased support. 

Effects of the Communities that Heal (CTH) intervention on perceived opioid-related community stigma in the HEALing Communities Study: results of a multi-site, community-level, cluster-randomized trial ðŸ”“

The Lancet Regional Health

Approximately 90% of Americans with opioid use disorder (OUD) do not receive treatment, and part of this may be related to community stigma against people who receive treatment and medication for OUD (MOUD). As part of the HEALing Communities Study, researchers implemented a community-level intervention including efforts to reduce community stigma. In this study, they assessed changes in perceived community stigma across 66 communities and found a decrease in stigma toward people who receive treatment for OUD and MOUD. However, the decrease in stigma toward MOUD was moderated in rural communities which had higher levels of perceived stigma toward MOUD than urban communities at baseline. These findings support implementation of efforts to decrease community stigma.

ASAM Annual

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The prevalence of cannabis use disorders in people who use medicinal cannabis: a systematic review and meta-analysis ðŸ”“

Drug and Alcohol Dependence

This systematic review and meta-analysis identified 14 studies regarding medicinal cannabis use and cannabis use disorder (CUD) that met inclusion criteria. Two studies were randomized controlled trials and almost all used DSM criteria for CUD. The meta-analysis resulted in a prevalence of CUD in those using medicinal cannabis of 29% (95% CI: 21-38%). The risk was greater in those using cannabis by inhalation, those younger (18-29yrs), and males. Those using cannabis for mental health (depression) and chronic pain were also at increased risk of CUD. Tolerance and withdrawal were the most frequently reported criteria. The authors conclude that the risk of CUD in those using medicinal cannabis is substantial.

Contemporary Management and Outcomes of Veterans Hospitalized With Alcohol Withdrawal: A Multicenter Retrospective Cohort Study

Journal of Addiction Medicine

In this retrospective cohort study, researchers evaluated alcohol withdrawal management between 2018 and 2019 across 19 Veteran Health Administration hospitals. Most patients were managed with symptom-triggered therapy (51%), while the others were managed with fixed dose plus symptom-triggered (25.9%), front loading plus symptom-triggered (10.3%), or fixed dose alone (3.4%) therapy. The medications most utilized were benzodiazepines including lorazepam (86.7%), chlordiazepoxide (32.8%), and diazepam (14.4%). Gabapentin (3.7%) and phenobarbital (5.6%) were less frequently utilized. The symptom-triggered and front loading plus symptom-triggered strategies were associated with shorter hospital stays. While lorazepam and phenobarbital were associated with longer stays and more complications. These findings are consistent with and support the current ASAM guidelines. 

Protocol for creating a dataset of U.S. state alcohol-related firearm laws 2000–2022 ðŸ”“

PLOS One

Firearms are a major source of preventable morbidity and mortality in the United States, contributing to over 48,000 deaths in 2022 and generating societal costs in excess of $500 billion. A body of work has examined the relationship between US state level firearm laws and health outcomes, generally finding that some firearm regulations are associated with lower firearm-related mortality. Alcohol has been identified as an additional risk factor for both homicides and suicide, and stronger state alcohol laws have been associated with lower rates of suicide. To date, there are no empirical studies that have investigated the impact of laws over a long period of time that target the intersection of alcohol and firearms. One reason for this may be because there is no existing dataset that includes the range of these state laws over time. This study describes the protocol for collecting, coding, and operationalizing these legal data.