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The ASAM Weekly for July 2nd, 2024

This Week in the ASAM Weekly

A new report from the World Health Organization estimates that 209 million people worldwide live with alcohol dependency and that nearly 5% of all deaths in 2019 can be attributed to alcohol consumption. Of note, the greatest proportion of alcohol-attributable deaths occurred among younger people, 20-39 years of age (WHO). Even though it is well-accepted that outcomes are more closely related to the amount rather than the type of alcohol consumed, it is important we understand how drinking patterns, drinking cultures, and eventually policies impact disease burden and mortality in different parts of the world (Addiction). 

For example, Sweden may be a rare example of a country that has been able to shift - likely through policy controls and monopolies- the country’s drinking culture. However, it seems their approach to people who use drugs, when compared to Denmark’s, represents a more punitive stance that reinforces the “master status of a stigmatized identity” which negatively impacts the self-perception of an individual, ultimately making it more difficult to receive help (Harm Reduction Journal).

A similar cultural dynamic underscores the unique burden of drug use disorders in the US. Opioid-related deaths in the US exceeded the global death toll by more than half in 2021, and age-adjusted mortality for OUD in the US is almost 13x higher than in the rest of the world (BMC Public Health). On the treatment side, studies show that up to 85% of Canadians with OUD have access to care. Compare that to the US, where we have only barely crossed the 20% mark (STAT News). 

Such differences are why it is important to have a global perspective on addiction. Biology, for the most part, is universal, and cultural norms can be shared broadly across regions, so policymakers may often be the differentiating factor. A horrifying example of this is Rodrigo Duterte (The New York Times). 

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

Invitation to Review: ASAM Draft Clinical Practice Guideline on Benzodiazepine Tapering

Through July 19th, the American Society of Addiction Medicine (ASAM) has made available for public comment a draft of its Clinical Practice Guideline on Benzodiazepine Tapering. For more information and instructions to review, please click here.


Lead Story

Global status report on alcohol and health and treatment of substance use disorders ðŸ”“

World Health Organization

This report utilizes data from the WHO member states to summarize alcohol consumption, its health consequences, and alcohol policies around the world. Overall, there was a decrease in alcohol consumption between 2010 and 2019, but alcohol-related deaths still accounted for 4.7% of all deaths in 2019. Despite the burden, there are still significant gaps in access to and types of treatment available worldwide, with the percentage of patients with substance use disorder receiving care ranging from 1% to 30% in countries that gather these data. The report makes several recommendations to address the concern, including a global advocacy campaign, increased training for health professionals at all levels, international knowledge transfers, and resource mobilization. 

Research and Science

Burden of drug use disorders in the United States from 1990 to 2021 and its projection until 2035: results from the GBD study ðŸ”“

BMC Public Health

Information about the health burden of drug use disorders (DUD) was obtained from the Global Burden of Disease Study and The Institute for Health Metrics and Evaluation. In 2019, over half of the world deaths due to DUDs were in the US where the DUD mortality rate was 12 times that in the rest of the world. In both the US and the rest of the world, the burden of DUDs was greatest in males and among those 15-45 years old, (and still heavy in the 45-65-year group for both sexes). From 1990 to 2021 the mortality rate increased for all subtypes of DUD in the US. The greatest rate of increase in mortality rate was for amphetamine use disorder, with an annual percentage change of 11.3%. Projecting the 1990-2021 data to 2035 predicts a 70% increase in the mortality rate due to DUDs in the US. The authors conclude that the burden of DUDs in the US is heavy and increasing.

A Self-Guided Internet-Based Intervention for the Reduction of Gambling Symptoms ðŸ”“

JAMA Network Open

This randomized clinical trial of 243 participants with self-reported gambling problems explored whether a self-guided internet-based intervention for individuals with gambling symptoms is effective in reducing problem gambling thoughts and behavior, comorbid depressive symptoms, and gambling-related thought distortions, and what factors moderate its effectiveness. The intervention group received access to the program during a 6-week period and improved significantly in gambling symptoms and depressive symptoms but not in gambling-specific thought distortions after treatment. Treatment expectation and symptom severity were moderating factors. These findings suggest that online self-help may be used effectively in the treatment of problem gambling symptoms.

Cannabis, Tobacco Use, and COVID-19 Outcomes ðŸ”“

JAMA Network Open

In the context of the global pandemic, researchers examined if cannabis use is associated with COVID-19 outcomes. In this cohort study of 72, 501 patients diagnosed with COVID-19 in a large medical center, individuals who used cannabis had a higher risk of hospitalization and intensive care unit admission compared with those not using cannabis after controlling for other risk factors. These findings suggest the need to evaluate the potential impact of cannabis use on COVID-19 outcomes given the growing legalized use of cannabis.

ASAM PAM 7

CO*RE REMS/ASAM Striking a Balance: Podcast Series

This free series consists of three 45-minute podcasts designed to empower clinicians to confidently manage opioid analgesics, from patient assessment and therapy initiation to modification, discontinuation, and patient counseling.


Learn More

“In Sweden you are worthless. In Denmark you get an identity again” – on being perceived and received as a person who uses drugs in different drug policy settings ðŸ”“

Harm Reduction Journal

In the 1980s, Sweden adopted a drug policy characterized by harsh penalties and significant stigma for people who use drugs (PWUD). Denmark has embraced harm reduction with supervised consumption sites, heroin-assisted treatment, and a rate of opioid substitution therapy twice that of Sweden. For this study, interviews were conducted with 17 PWUD, who were Swedish citizens and had traveled to Denmark. Swedish policies resulted in feelings of worthlessness and physically hiding from the public. One participant noted that in Sweden, her bag was searched during in-patient treatment, whereas in Denmark they “trust me … that meant so much … I don’t want to let them down.” After a relapse in Denmark, a participant noted, they “didn’t punish me.” In Sweden, you are punished with a reduced dose, so “you start lying to them instead.” The authors conclude that positive interactions with providers and the public may foster empowerment and well-being in PWUD.

Cebranopadol, a novel long-acting opioid agonist with low abuse liability, to treat opioid use disorder: Preclinical evidence of efficacy

Neuropharmacology

In this study, the authors use a rat model to evaluate cebranopadol, a pan-opioid receptor agonist, for its potential in treating opioid use disorder (OUD). Rats sensitized to heroin through operant self-administration were given cebranopadol to assess the effects of self-administration. There was a decrease in heroin self-administration and cebranopadol appeared to have low abuse potential and high safety. Based on these findings, the authors recommend additional studies, including clinical trials, for use of cebranopadol for treatment of OUD patients.

Correlation of striatal dopamine D2/3 receptor availability with GABA level in the anterior cingulate cortex in healthy controls but not in alcohol-dependent subjects and individuals at high risk: A multimodal magnetic resonance spectroscopy and positron emission tomography study ðŸ”“

Addiction Biology

Previous work by this group has found reduced dopamine receptor availability in the striatum of subjects with alcohol use disorder (AUD). This study investigates GABA and glutamate levels in the anterior cingulate cortex (ACC) as a possible regulator of dopamine in the striatum. AUD patients (n=19) were scanned following detoxification and approximately 1 month abstinent and compared to healthy controls and subjects at high risk for AUD (HR = AUDIT score>8). PET imaging was used to measure dopamine receptors and MRI was used to measure GABA and glutamate levels. In healthy controls, GABA levels in the ACC were negatively correlated with dopamine receptor availability in the striatum. However, this correlation was absent in patients at HR or with AUD, possibly representing a disrupted regulatory mechanism. Further studies could help define the role of this mechanism in AUD.