American Society of Addiciton Medicine

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The ASAM Weekly for December 17th, 2024

This Week in the ASAM Weekly

There are so many aspects of addiction that we can focus on. The opioid crisis points us toward overdose deaths, which leads us toward illicit drug supplies and the public’s awareness of fentanyl. The reemergence of carfentanil, in a way, emphasizes that danger comes from potency (MMWR).

Abstinence, on the other hand, could be considered as a zero-potency state of addiction, but a focus on abstinence as the goal will miss the many who reduce their substance use, successfully (JAMA Psychiatry). Even a consideration of abstinence and quit attempts may not align with harm reduction, wellness, or quality of life, questioning whether we should focus much on abstinence as an outcome (Drug and Alcohol Dependence). 

Sometimes, bigger things than addiction become our focus. Substantial differences exist for how certain racial-ethnic groups seek out (or don’t) addiction treatment (Psychiatric Services). A group from Boston University and Medical Center have published details of their project to address addiction treatment’s racist past and make it more effective and equitable for Black people (Social Science and Medicine).

Some things, though, take time before they come into focus. Consider the connections between obesity and addiction, for example. Obesity affects nearly half of all Americans. Big Tobacco hijacked hunger and introduced us to ultraprocessed foods (New York Times). Eli Lilly will be studying GLP-1 drugs to treat substance use disorders because, as its CEO states, they are anti-hedonic meds (STAT). 

Anti-hedonic meds? If that isn’t a call to action for an addiction specialist, then maybe calling obesity a brain disease is (Endpoints News).

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

 
 

Lead Story 

The impact of schizophrenia genetic load and heavy cannabis use on the risk of psychotic disorder in the EU-GEI case-control and UK Biobank studies 🔓

Psychological Medicine

Using data from the EU-GEI case-control study and UK Biobank, researchers examined the independent and combined effect of heavy cannabis use and schizophrenia polygenic risk score (PRS) on risk for psychosis. Schizophrenia PRS and cannabis use independently increased risk of psychosis. Schizophrenia PRS was not associated with patterns of cannabis use. It was associated with lifetime and daily cannabis use without psychosis, but the effect was substantially reduced when cannabis use disorder (CUD) PRS was included in the model. Regular users of high-potency cannabis had the highest odds of being a case independently of schizophrenia PRS. Regular use of high-potency cannabis remains a strong predictor of psychotic disorder, independent of schizophrenia PRS. Schizophrenia PRS does not seem to be associated with heavy cannabis use. These are important findings, at a time of increasing use and potency of cannabis worldwide. 

 

Research and Science 

Capturing the Full Range of Buprenorphine Treatment Response 

JAMA Psychiatry

This study examined if the reliance on abstinence-based treatment outcomes has failed to capture the full continuum of treatment response to buprenorphine plus medical counseling (BUP+MC) for opioid use disorder (OUD). In data from 4 harmonized clinical trials of adults (N = 869) with OUD receiving BUP+MC, only 377 patients (43%) would have been labeled a treatment success using an abstinence-based success rule. However, on average, patients labeled as unsuccessful reported substantial decreases in illicit opioid use from a mean of 6.29 days per week pretreatment to 1.51 days per week, by week 12. In this study, many patients experienced a substantial treatment response to BUP+MC short of total abstinence. 

Embracing anti-racism: Co-creating recommendations with Black people for how addiction treatment needs to change 🔓

Social Science and Medicine

Significant disparities exist in health outcomes, mortality, and social consequences for substance use between Black and White people. This paper provides specific recommendations to address disparities; these recommendations were developed by a community-engaged initiative that included both researchers and community members with lived experience with substance use disorders (SUD). One of the chief needs identified was the hiring of Black staff and people of color in treatment programs. Other recommendations include providing professional development to support Black patients; eliminating punitive responses; providing culturally-tailored care; ensuring accountability at all levels of programs to address racist behaviors; and finally, acknowledging and addressing trauma in SUD treatment, including racial trauma. 

Association between buprenorphine dose and outcomes among pregnant persons with opioid use disorder 

American Journal of Obstetrics and Gynecology

This study obtained data on buprenorphine use during pregnancy for 2,925 patients from the Pennsylvania Medicaid database. Researchers found 3 overall patterns of buprenorphine use: use before and during pregnancy (45%), use initiated during pregnancy (40%), and use discontinued during pregnancy (15%). Consistent use of at least moderate doses of buprenorphine was associated with increased odds of continuing buprenorphine postpartum (OR 1.81), whereas lower doses or discontinuation during pregnancy was associated with lower odds (OR 0.55) of continuing. Odds of neonatal abstinence syndrome were not related to dose. Nonfatal overdose was more likely with lower dose or discontinuation of buprenorphine during pregnancy. Researchers concluded that higher dose and longer duration of buprenorphine use during pregnancy was associated with improved outcomes. 

 

Social and Environmental Predictors of Youth Alcohol and Cannabis Initiation Risk: The Moderating Role of Family History of Substance Use Disorders 

Substance Use and Misuse

Utilizing data from a longitudinal youth cohort, this study evaluated impact of social and environmental factors on alcohol use initiation (AUI) and cannabis use initiation (CUI). Specifically, researchers examined social relationships (mother-youth, father-youth, and risky peers) and local-home factors (socioeconomic status (SES) and neighborhood safety) and potential interaction with family history (FH+) of substance use disorder (SUD). Overall, FH+ youth had increased rates of AUI (HR=1.36) and CUI (HR=2.36), and starting at younger age and association with risky youth also increased risk of AUI and CUI. Positive father-youth relationship and mother-youth relationship were protective, though not statistically significant, for AUI and CUI respectively, though FH+ did attenuate the mother-youth impact. 

 

Learn More 

Racial-Ethnic Differences in Lack of Treatment Among Care-Seeking People With Substance Use Disorders 🔓 

Psychiatric Services

Using data from the National Survey on Drug Use and Health, this paper reports reasons for not accessing treatment for substance use disorder (SUD) by race-ethnicity. Overall, only 6.4% of respondents had received treatment in the previous year. Among those who perceived the need for treatment, the most reported reason for not getting treatment was the belief that they should be able to handle use on their own, with this response being much more common among non-Hispanic Black persons. Among Hispanic persons, not knowing where to get treatment was the most common reason they did not receive treatment. Both non-Hispanic Black and Hispanic persons reported not being able to find a program or provider they wanted to go to at higher rates than non-Hispanic White persons. These results highlight the importance of destigmatizing SUD and the need for inclusive and culturally appropriate treatment approaches.

Beyond the first try: How many quit attempts are necessary to achieve substance use cessation?

Drug and Alcohol Dependence

Members (n=421) of an online recovery community (International Quit and Recovery Registry) were invited to complete an online survey concerning their substance use and the number of quit attempts to achieve abstinence. The most common drug of choice was alcohol (41%), followed by opiates (16%) and stimulants (15%). The longest duration of use was 23 years for alcohol and nicotine; opioids and stimulants had a mean of 11 years of use. The median number of quit attempts was 5 for nicotine, 4 for opioids, 3.5 for alcohol, and 3 for stimulants. Hallucinogens had the lowest number of quit attempts, at 1. When the results were adjusted for severity of SUD, the number of quit attempts for opioids was significantly higher than for other substances. Those with mild severity SUD (by DSM criteria) had fewer quit attempts than moderate severity, and severe SUD had the most quit attempts (all p<.001). 

Detection of Illegally Manufactured Fentanyls and Carfentanil in Drug Overdose Deaths — United States, 2021–2024 🔓

Morbidity and Mortality Weekly Report

In 2023, approximately 72,000 — or nearly seven in 10 — drug overdose deaths in the United States were estimated to involve illegally manufactured fentanyls (IMFs). Carfentanil, a fentanyl analog 100 times more potent than fentanyl, has reemerged in the US drug supply. Using CDC’s State Unintentional Drug Overdose Reporting System data, this report describes trends in overdose deaths from January 2021 to June 2024, both overall and with IMFs. The number of overdose deaths with IMFs detected declined from 2022 to 2023 in the Northeast, Midwest, and South regions. However, deaths in the West increased by 33.9%. The percentage of deaths with IMFs detected remained steady at approximately 70–80% in the Northeast, Midwest, and South. In contrast, the percentage of deaths with IMFs detected in the West increased from 48.5% during January–March 2021 to 66.5% during April–June 2024. Overdose deaths with carfentanil detected increased approximately sevenfold, from 29 during January–June 2023 to 238 during January–June 2024. During January 2023–June 2024, overdose deaths with carfentanil detected were reported in 37 states. Overdose prevention efforts that address the widespread presence of IMFs, including carfentanil, and that can rapidly adapt to other potent opioids in the drug supply might result in lasting reductions in overdose deaths across the entire United States.