This Week in the ASAM Weekly

A study from the American Journal of Psychiatry is challenging the allostasis theory of addiction. If you combine that with a podcast, news releases, and an editorial, there is much to consider. Does it change the the “self-medication hypothesis,” undercount how addiction changes the brain, or demonstrate a difference between those who seek treatment and those who don’t? Are we witnessing a phenomenon that is not shared across all substances of addiction? If you’re a weekly newsletter, the safest answer to such questions is “all of the above.” Or is it?

For example, a largest-of-its-kind study is helping answer a major question about cannabis and the brain. Both acute and heavy lifetime use are associated with reduced brain activity involved with working memory (JAMA Network Open). Does that mean the effects are permanent?

As a newsletter, we are able to sometimes respond to big questions with smaller ones and find answers in unlikely places. An article about young French adults embracing non-alcoholic wines makes a poignant observation about decreasing rates of alcohol use— “young people are focused on controlling their online image” and binge-drinking just doesn’t fit well with that (The Christian Science Monitor). 

Sometimes a newsletter can bring attention to questions that aren’t being asked enough. A rather colorful perspective urges us to not waste the opportunity of developing scientifically rigorous methods for assessing cannabis impairment, both on the road and at work. Otherwise, the police will do it for us (JSAD).

Whatever role a newsletter might play in disseminating scientific information, a valuable function of this is receiving feedback. If you have any questions (or answers) about what you read in the ASAM Weekly, let us know at ASAMWeekly@ASAM.org. We always appreciate it.

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  

Real-Time Assessment of Alcohol Reward, Stimulation, and Negative Affect in Individuals With and Without Alcohol Use Disorder and Depressive Disorders 🔓

American Journal of Psychiatry

A commonly held model of addiction posits that as addictions develop, there is progression from positive reinforcement to negative reinforcement to ameliorate withdrawal symptoms. In this study, researchers examined the subjective response to alcohol among persons with and without alcohol use disorder (AUD) and with or without comorbid depression. Regardless of the presence of comorbid depression, persons with AUD reported pleasurable effects, including stimulation and hedonic reward, after consumption of alcohol. In contrast, among those without AUD, the positive effects were less substantial. Participants did report reduction in negative affect, but the effects were relatively small. These findings suggest that positive reinforcement is sustained in the progression of AUD and the reward-sensitive stage may exist along with negative reinforcement. 

Research and Science 

Stimulant-involved overdose deaths: Constructing dynamic hypotheses 

International Journal of Drug Policy

Researchers conducted interviews and group model building workshops in Massachusetts and South Dakota to examine the rise in stimulant (cocaine and/or methamphetamine)-only and opioid and stimulant-involved overdose deaths. For stimulant-only overdose deaths, three dynamic hypotheses emerged: (1) disbelief that death could occur from stimulants alone, and doubt in testing capabilities to detect fentanyl; (2) the stimulant supply has changed, leading to higher unpredictability and thus higher overdose risk; and (3) long-term stimulant use contributing to deteriorating health and increasing overdose risk. For stimulant- and opioid-involved overdose deaths, three dynamic hypotheses included: (1) accidental exposure to fentanyl from stimulants; (2) primary stimulant users increasingly using opioids, often with resignation; and (3) primary opioid (especially fentanyl) users increasingly using stimulants to balance the sedating effect of fentanyl. These hypotheses likely each explain a portion of the recent trends in stimulant-involved overdoses underscoring the need for research to develop targeted public health interventions, including analyzing the extent of the effect of contamination on overdoses, reducing confusion about the stimulant supply, and examining historical stimulant use trends.

Access to Firearms and Opioids Among Veterans at Risk for Suicide 🔓

JAMA Network Open

This cross-sectional study of 38,454 veterans at risk for suicide who received suicide safety plans examined the prevalence of reported access to firearms and opioids and implementation of related interventions. The study found that 28% of veterans reported access to firearms and 5% reported access to opioids. As documented by clinicians in a note template, firearm storage and overdose were discussed with 79% to 98% of veterans, but relatively few accepted firearm cable locks and/or naloxone. These findings suggest that completion of a note template may encourage routine discussion of risks related to firearms and opioids, although reported access to firearms was lower than expected.

Brain Function Outcomes of Recent and Lifetime Cannabis Use 🔓

JAMA Network Open

There is evidence that adolescent cannabis use is associated with reduced thickness of both left and right prefrontal cortex in a manner reflecting CB1 receptor density. This study used data from the Human Connectome Project (HCP), including functional MRI data and the results of 7 brain function tasks. Of the 1,003 adults in the HCP, 9% were heavy cannabis users. Among these heavy cannabis users, there was a reduction in brain activity during a working memory task. The brain regions involved in the working memory task are known to have a high density of CB1 receptors, and receptor availability is known to be reduced by daily cannabis use. This effect on working memory remained after excluding individuals with recent cannabis use (those with a urine screen positive for cannabis) suggesting that this was not simply the result of acute intoxication. The researchers concluded that this reduction in working memory with heavy lifetime cannabis use may be long lasting.

Learn More 

Alcohol labelling and cancer: a way to empower consumers despite industry opposition 🔓 

BMJ

A recent US surgeon general’s advisory states that alcohol is a cause of preventable cancer – for example, 16% of breast cancer cases are due to alcohol use — and suggests product labeling to increase awareness of this risk. The author cites several studies on the alcohol industry’s efforts to influence the perception of alcohol’s harms, similar to strategies used by the tobacco industry. Strong government action is needed to support alcohol labeling.

Perspective: Pseudoscience and the Detection of Marijuana-Based Impairment—We Can and Must Do Better 🔓 

Journal of Studies on Alcohol and Drugs

This Perspective piece stipulates that existing tools for making workplace and roadside determinations of marijuana-based impairment are inadequate. They either merely imitate tools used to identify alcohol-based impairment without taking into account important differences between these molecules, or they are pseudoscientific “police science.” The legalization of marijuana use must be accompanied by urgent efforts toward and dedicated funding for the development and implementation of practical, accurate, and objective methods for on-the-spot determination of whether a person is dangerously impaired by marijuana.

Cannabis Marketing Strategies in the United States: A Descriptive Analysis of Four Prominent Companies 

Substance Use and Addiction Journal

As more states have legalized recreational cannabis, the marketing of cannabis is of public health interest as it can influence public perceptions and use, particularly in youth. In this context, the authors evaluated the advertising of four cannabis companies in 2020 and 2021. During that period, these companies spent $488,617 on advertising, with the majority being digital and focused on product type, discounts or promotions, and seasonal ads. In addition, most of the ads featured gifs or cartoon-like images. While regulations for cannabis advertising do exist in some states, they vary, and it is unclear how much they are enforced. The authors suggest ongoing monitoring of advertising is needed to inform regulations and public health campaigns and assess compliance with regulations.

Larsucosterol for the Treatment of Alcohol-Associated Hepatitis

New England Journal of Medicine

Larsucosterol is an endogenous cholesterol metabolite that has been shown to have possible efficacy in the treatment of alcoholic hepatitis (AH). Larsucosterol stimulates hepatic regeneration, improves cell survival, and has other effects that may improve survival in patients with AH. In this randomized, double-blind, placebo-controlled trial of larsucosterol in 307 patients with severe AH, the primary endpoint was mortality or liver transplant at 90 days. Neither of the two doses of larsucosterol (30mg or 90mg) produced statistically significant results at 90 days. However, there were reductions in mortality, particularly in patients treated in the United States, that convinced the authors that further studies are warranted.

In The News

FDA Approves Novel Non-Opioid Treatment for Moderate to Severe Acute Pain 🔓

US Food & Drug Administration (FDA)

Young French are dropping wine for nonalcoholic alternatives 🔓

The Christian Science Monitor

Cannabis Takes On Superbugs: Could This New Drug 'Change Infection Treatment Forever'? 🔓

Benzinga

Here's what dopamine, the 'happy hormone,' actually does

National Geographic

Seattle’s ‘stay out’ zones for drug arrests go mostly unused 🔓

The Seattle Times