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The ASAM Weekly for April 30th, 2024

This Week in the ASAM Weekly

Confronting Addiction from Prevention to Recovery

Petros Levounis, MD, MA
President, American Psychiatric Association

Over the past year as president of the American Psychiatric Association (APA), my presidential theme has been “Confronting Addiction from Prevention to Recovery.” This initiative has focused on four of the biggest areas—three persistent and one emerging—in addiction medicine: vaping & tobacco, opioids, alcohol, and technological addictions. Each of these issues has been addressed in quarterly educational campaigns that have seen APA member experts creating resources aimed at the general public and physicians alike.

I was inspired to undertake this initiative as it played to our strengths as addiction professionals, my personal strengths as an addiction psychiatrist, and the APA’s outstanding ability to affect meaningful change from resolving scientific intricacies in the Diagnostic and Statistical Manual of Mental Disorders (now in its fifth, text revised, edition, the DSM-5-TR) to testifying before congress during some of the most consequential hearings of our times. 

We are in a unique moment where we are lucky to have incredible science, research, and tools that can help in the treatment of substance use disorders (SUDs). Some of these, like naloxone and buprenorphine for example, can mean the difference between life and death for someone who lives with opioid use disorder. 

Therein lies our challenge. Many of our patients are either unaware of or unable to access such treatments, and many clinicians are hamstrung by regulatory hurdles and legal grey areas that can lead to hesitancy in prescribing treatments that are not only beneficial for a patient, but also perfectly legal.

Read the full editorial.

 

The ASAM/AAAP Clinical Practice Guideline on the Management of Substance Use Disorder

The American Society of Addiction Medicine (ASAM) and American Academy of Addiction Psychiatry (AAAP)’s jointly developed Clinical Practice Guideline on the Management of Stimulant Use Disorder has been published in the Journal of Addiction Medicine and is available open access here.

ASAM and AAAP have also developed a pocket guide version of the guideline to serve as a quick-reference tool providing instant access to the guideline recommendations in a clear, concise format. The provider pocket guide digital version is free and can be accessed here. 

A patient version of this pocket guide will also be made available soon.


Lead Story

Association of regular opioid use with incident dementia and neuroimaging markers of brain health in chronic pain patients: analysis of UK Biobank ðŸ”“

The American Journal of Geriatric Psychiatry

In this cohort study, researchers examine the association between regular opioid use in patients with chronic pain and development of dementia over 15 years of follow-up. Regular opioid use versus non-opioid analgesic use in this population was associated with increased risk of incident dementia (HR=1.18 CL,1.08-1.30). In addition, there appeared a dose-dependent response with those receiving more prescriptions being more likely to develop dementia: 1-5 prescriptions OR=1.21, 6-20 prescriptions OR=1.27, and >20 prescriptions OR=1.43. Finally, in brain imaging, those with regular opioid use exhibited lower total gray matter and higher white matter hyperintensities. While additional research may be needed to support causality, the authors suggest these findings support caution in regular use of opioids for chronic pain. 

Research and Science

Weaning buprenorphine in pregnant patients ðŸ”“

The Journal of Maternal-Fetal & Neonatal Medicine

This study took place at the University of Kentucky in a program offering pregnant patients with OUD both obstetric and behavioral healthcare. Patients who volunteered to wean from buprenorphine during pregnancy (n=39) were compared to a control group who did not wean (n=295). The wean group had significantly lower buprenorphine doses at delivery (4.4mg wean v. 13.0mg controls, p<0.0001), and 26% of the wean group completely reduced the dose to 0. The wean group had a significant decrease in the incidence of NOWS compared to controls (23% wean v. 47% controls, p=0.006). There were no maternal overdoses during pregnancy and return to use occurred in a similar percentage of wean patients and controls (25% wean v. 39% controls, p=0.16). There were 4 deaths, all in the postpartum period, none in the wean group, and all due to pregnancy related causes. 

Drugs of abuse hijack a mesolimbic pathway that processes homeostatic need 

Science

This study compared the response of key reward circuits activated by hunger and thirst with the response to morphine and cocaine in the same animals. The protein RHEB (Ras homolog enriched in brain), a signaling partner of mammalian target of rapamycin, was found to be a crucial molecular substrate that enables drugs to gain access to neurons that process natural reward. This molecular mechanism is engaged in dissociable ensembles of neurons of the nucleus accumbens and are at the center of the addictive effects of these drugs, where conflict between drug-taking and the homeostatic regulation of hunger and thirst takes place.

ASAM PAM 7

ASAM Clinical Algorithm Subcommittee

As a part of ASAM’s mission to define and promote evidence-based best practices in addiction prevention, treatment, remission, and recovery, the ASAM Clinical Algorithm Subcommittee will collaborate with ASAM staff in refining the 4th Edition clinical algorithms for ASAM Criteria based assessment tools. 


Learn More

Is low-level alcohol consumption really health-protective? A critical review of approaches to promote causal inference and recent applications ðŸ”“

Alcohol Clinical and Experimental Research

This paper discusses the health benefit claims for low-level alcohol drinking, the “J-shaped” curve. Past studies have been observational; these can show associations between health outcomes and levels of alcohol use but can’t prove causation. Confounders such as socioeconomic status are related to both health outcomes and levels of alcohol use. Randomized controlled trials overcome confounders, but long-term alcohol use trials would be complex and expensive. New techniques, both statistical (G-methods) and genetic (Mendelian Randomization) can infer causation from observational data sets. Recent studies using these techniques suggest low-level drinking may be protective for some conditions (depression), but for others it is less beneficial than previously thought (type 2 diabetes) or the benefits disappear (cardiovascular disease). The authors conclude that past studies overestimate the benefits and underestimate the harms of low-level drinking.

Untreated Psychiatric and Substance Use Disorders Among Caregivers With Children Reported to Child Protective Services ðŸ”“

JAMA Health Forum

Parent engagement in psychiatric and substance use disorder treatment can prevent child maltreatment and family separations. In this case-control study, less than 50% of caregivers with Medicaid coverage with mental health or substance use disorders whose children were referred to child protective services received counseling or substance use disorder medications. Medicaid and child welfare programs should enhance caregiver receipt of mental health and substance use disorder treatment to improve parenting skills and prevent child maltreatment and family separations.

Why Patients Leave: The Role of Stigma and Discrimination in Decisions to Refuse Post-Overdose Treatment ðŸ”“

The American Journal of Bioethics

Emergency departments (ED) see over 600,000 non-fatal overdoses annually and many of those patients refuse care after reversal. The authors of this editorial note that while some believe this response is irrational and attribute it to the opioid use disorder (OUD), they argue this response is rational. This refusal occurs in response to stigma within the health care system and criminalization. This population faces heightened surveillance and coercion in the health system, including mandated reporting, involuntary holds, and documentation in health records. Finally, they are frequently not offered appropriate treatment to manage withdrawal or services such as harm reduction or medication for OUD. The authors further suggest harm reduction settings, such as syringe service programs and overdose prevention centers are better equipped to help this population and have been shown to decrease ED visits.