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The ASAM Weekly for July 30th, 2024

This Week in the ASAM Weekly

Does Rescheduling Cannabis Make Sense? 

By Stuart Gitlow, MD, MPH, MBA, DFAPA, DFASAM
Past Chair, American Medical Association Council on Science & Public Health 
Past President, American Society of Addiction Medicine 

On May 16, the Department of Justice (DOJ) proposed moving marijuana from Schedule I to Schedule III of the Controlled Substances Act. Between now and November’s election, there will be considerable discussion regarding rescheduling. Of importance in this discussion is the fact that marijuana remains at this moment illegal in all 50 states under federal law, so, for example, a dispensary selling marijuana products is acting criminally whether or not such sales are permitted under state law. A physician accepting payment for recommending marijuana and filling out a relevant state form could be charged federally with conspiracy related to the sale of an illegal product. Also important in the discussion is the fact that marijuana is a plant, not a drug. The plant simply happens to contain psychoactive substances, along with thousands of other molecules, all of which may or may not have short- or long-term effects that have not been studied specifically. Sufficient scientific evidence that the plant itself has beneficial medical utility is limited in scope and of poor strength, but several components of the plant do have such utility and have been separately Scheduled and marked as indicated for a number of very limited medical conditions.

The Controlled Substances Act places regulated substances into one of five Schedules based upon medical use, potential for abuse, and safety or dependence liability. Under the law, eight issues must be considered to determine which Schedule is utilized for any one product. Five of the eight deal explicitly with abuse and dependence issues or risk to the public health. Two deal with scientific knowledge and medical utility and applicability. The remaining issue simply asks whether the substance is a precursor to another controlled substance.

Read the full editorial here.

Lead Story 

Psilocybin desynchronizes the human brain ðŸ”“

Nature

To assess how human brain network changes relate to the subjective and lasting effects of psychedelics, this study tracked individual-specific brain changes with longitudinal precision functional mapping (roughly 18 magnetic resonance imaging visits per participant). Psilocybin massively disrupted functional connectivity (FC) in the cortex and subcortex, acutely causing more than threefold greater change than methylphenidate. These FC changes were driven by brain desynchronization across spatial scales (areal, global), which dissolved network distinctions by reducing correlations within and anticorrelations between networks. Persistent reduction of hippocampal-default mode network connectivity may represent a neuroanatomical and correlate of the proplasticity and therapeutic effects of psychedelics.

Research and Science 

Prenatal Cannabis Use and Maternal Pregnancy Outcomes ðŸ”“

JAMA Internal Medicine

This cohort study of 316,722 pregnancies explored whether prenatal cannabis use is associated with maternal health outcomes during pregnancy. Prenatal cannabis use was associated with an increased risk of gestational hypertension, preeclampsia, weight gain greater and less than guidelines, and placental abruption, as well as reduced risk of gestational diabetes. No association was found with eclampsia, placenta previa, placenta accreta, or severe maternal morbidity. The results of this study suggest that the association between prenatal cannabis use and maternal health is complex and there is a need for continued research to understand how prenatal cannabis use affects the health of pregnant individuals.

Prescription Opioid Use Disorder Among Adults Reporting Prescription Opioid Use With or Without Misuse in the United States ðŸ”“

Journal of Clinical Psychiatry

The authors used the 2021 National Survey on Drug Use and Health to explore the prevalence and characteristics of prescription-related opioid use disorder (POUD). Overall, they found that approximately 27% (68.5 million) of the population over 18 had used prescription opioids in the last year and among those, 12.1% (8.3 million) misused prescription opioids and 7% (4.8 million) had POUD. While overall POUD was 4.5 times more prevalent among those reporting misuse, the majority with POUD (62%) did not report misuse. The vast majority of those with POUD not reporting misuse had mild or moderate disease. The authors noted that while screening for misuse is important when prescribing opioids, that alone can miss persons with POUD, and screening for POUD itself is needed.

Learn More 

Behind the heterogeneity in the long-term course of first-episode psychosis: Different psychotic symptom trajectories are associated with different patterns of cannabis and stimulant use ðŸ”“

Schizophrenia Research

To investigate the association between cannabis and stimulant use and the course of psychosis, this study enrolled 192 patients with a first episode of psychosis and followed them for 10 years. Patients whose psychosis was the result of substance use or other organic illnesses were excluded from the study. Researchers identified four patterns of psychotic symptoms, two of which had little association with substance use – ie, persistent psychotic symptoms (22%) and stable psychotic remission (54%). The other two patterns, delayed remission over the first 5 years (16%) and psychotic relapse with symptoms during years 3-8 (8%), were associated with stimulant use. Heavy cannabis use was also associated with the delayed remission pattern. The effects of stimulant use were seen even with sporadic use.

Shared genetics of ADHD, cannabis use disorder and cannabis use and prediction of cannabis use disorder in ADHD

Nature Mental Health

This study notes that individuals with ADHD have a 23% prevalence of substance use disorders. This study performed a genome-wide association study to identify loci associated with both ADHD and cannabis use disorder (CUD) or cannabis use (CU). Researchers found 36 loci associated with ADHD and CUD, and 10 loci associated with ADHD and CU. Not only were more ADHD-CUD loci found, but they also had greater expression in brain tissue and during all stages of brain development than ADHD-CU loci. These results confirm that individuals with ADHD are at high risk for CUD. The results could also help to develop a genetic prediction tool to identify individuals with ADHD at high risk for CUD, who could benefit from early intervention.

A Source Control Model for Treatment-Resistant Substance Use Disorder

Journal of Addiction Medicine

In this commentary, the authors propose the use of a “source control” model for treatment-resistant substance use disorder (TR-SUD). The source control model is used in infectious disease and refers to an underlying cause for ongoing infection, such as an abscess. When considering TR-SUD, this model suggests examining other “causes” of ongoing substance use, such as stressors, untreated trauma, and co-occurring medical or psychiatric issues. The model has the benefits of using the concept of multiple factors contributing to SUD, destigmatizing SUD by describing it like other medical conditions, identifying a need for multimodal treatment, and encouraging ongoing evaluation of patients for contributing factors.