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The ASAM Weekly for July 16th, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

Whether they are personal, political, or data-driven, many of this week’s publications are compelling for different reasons but are all pieces of important addiction topics: methadone access, addiction treatment in carceral settings, medical cannabis laws, industry sponsorship, and accountability for the opioid crisis.

For example, an individual with both pain and addiction was able to lead a normal life because his physician prescribed him methadone. After his doctor retired, he experienced the challenges of receiving care at an opioid treatment program (Filter). 

Individuals in carceral settings deserve addiction treatment that works. The National Institutes of Health is funding partnerships across the correctional system to bring data-driven changes to communities and the individuals who need support (STAT).

More than 40 states in the US have implemented medical cannabis programs; however, insufficient guidance and inadequate regulatory framework create a system that leaves many providers confused even when they want to help (Journal of Addiction Medicine). Medscape may have thought it was helping to promote harm reduction but instead developed continuing medical education that parroted marketing material from Phillip Morris International (JAMA).

Lastly and unsurprisingly, the Sackler family saga continues as the Supreme Court ruled Purdue Pharma's bankruptcy settlement cannot shield family members from further lawsuits (Reuters).

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

Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study ðŸ”“

BMC Medicine

This study examined the relationship between benzodiazepine (BZD) use and dementia, using data from the population-based Rotterdam (Netherlands) study started in 1990. For 5,443 participants, BZD use during the 15 years from 1990 to 2005 was compared to dementia screens performed through 2020. Half of the participants had used BZD at some time during the 15-year baseline, and 13% developed dementia. Overall, there was no association between BZD use and dementia risk. However, the use of BZD as an anxiolytic in higher doses was associated with dementia risk (HR=1.3). The authors note that BZD with longer half-life are used as anxiolytics, whereas short half-life BZD are used as sedative-hypnotics. A reduction in hippocampal volume on MRI was also associated with BZD use. Although there was no association of BZD use with dementia risk, some associations were observed that deserve further study.

Research and Science

Heavy Lifetime Cannabis Use and Mortality by Sex ðŸ”“

JAMA Network Open

This cohort study explored the association between cannabis use and all-cause, cardiovascular disease (CVD), and cancer mortality. Of 121,895 participants, in the fully adjusted model among females, the risk for CVD mortality was significantly higher among heavy cannabis users compared with never users; there was no association among males. No association was observed among females or males for all-cause and cancer mortality. The findings suggest that heavy cannabis use is associated with CVD mortality among females.

Opioid-induced neuroanatomical, microglial and behavioral changes are blocked by suvorexant without diminishing opioid analgesia 

Nature Mental Health

Chronic opioid exposure has been shown to increase the number of hypocretin (Hcrt) neurons and axonal projections to the ventral tegmental area which has been linked to reward task performance in animal models. Hcrt is released in human brains during enjoyable activity and Hcrt neurons are increased in human brains with opioid use disorder (OUD). In this mouse model, co-administered suvorexant (dual Hcrt receptor antagonist) with morphine prevented the morphine-induced changes in the number and size of Hcrt neurons. In addition, it did not block analgesic effects, reduced opioid withdrawal symptoms, and prevented morphine anticipatory behavior. While additional research will be needed, Hcrt receptor antagonists may significantly reduce the risk of developing OUD in humans when given with opioids for pain relief.

Effects of moderate alcohol consumption and hypobaric hypoxia: implications for passengers’ sleep, oxygen saturation and heart rate on long-haul flights

Thorax

During commercial airline flights, regulations allow a minimum cabin pressure equivalent to 2,438m (8,000ft) elevation. This study measured the effect of moderate alcohol consumption (BAL~0.06%) on oxygenation during sleep in healthy individuals in this hypobaric environment. Sleep studies were recorded in 48 healthy individuals using an altitude chamber to simulate airline cabin pressure. At sea level pressure, alcohol decreased oxygen saturation during sleep from 96% to 95%. At simulated airline cabin pressure, alcohol reduced oxygen saturation during sleep from 88% to 85% with an associated increase in heart rate from 72bpm to 87bpm. The combination of reduced cabin pressure, moderate alcohol consumption, and sleep stresses the cardiovascular system even in healthy individuals.

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

Concurrent Use of Tobacco and Cannabis and Internalizing and Externalizing Problems in US Youths ðŸ”“

JAMA Network Open

This cross-sectional study examined whether concurrent use of tobacco and cannabis among youths is associated with higher or lower levels of mental health problems than the use of either substance alone. In a national sample of 5,585 youths aged 14 to 17 years, concurrent use was associated with almost twice the odds of reporting higher levels of externalizing problems compared with tobacco or cannabis use exclusively, but this association did not hold for internalizing problems. These findings suggest that integrated treatment of mental health and tobacco and cannabis use may be beneficial in addressing these comorbidities among youth.

Addressing Confusion and Inconsistencies Surrounding the Provider Role in Medical Cannabis Programs

Journal of Addiction Medicine

This commentary notes that over 40 states have medical cannabis programs that often require an assessment by a medical provider. Initially, medical cannabis was used as compassionate care for terminal or untreatable conditions but is increasingly promoted for a wide variety of medical issues. Cannabis products do not have FDA approval for safety and efficacy, so providers are left to evaluate the evidence. Surveys show most providers feel unprepared for this role. The authors suggest that medical education include cannabis topics, increased conference and CME coverage of medical cannabis, and the development of guidelines. Guidelines should cover assessment, indications with evidence of efficacy, and ongoing care to monitor for response to treatment and adverse effects including substance use disorders. 

The Tobacco Industry Has No Business Funding Continuing Medical Education

JAMA

The for-profit medical media company Medscape promoted a series of continuing medical education (CME) courses funded by a grant from tobacco company Philip Morris International (PMI). These activities were certified by the Accreditation Council for Continuing Medical Education (ACCME), along with other health care professional education organizations. PMI’s hypocrisy in promoting a harm reduction agenda is highlighted by its aggressive marketing of Marlboro, the world’s leading cigarette brand, including campaigns manifestly targeting youth. As many accredited CME providers may be tempted by PMI’s financially generous proposals, the authors urge professional organizations to work with accreditation bodies to adopt policies prohibiting tobacco industry funding of health care professional education.