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The ASAM Weekly for February 18th, 2025

This Week in the ASAM Weekly

Nicholas Kristoff, a New York Times opinion columnist, writes an impassioned profile about a hometown friend and the conflicts of having a progressive view on drug addiction. It’s anecdotal evidence (N=1) critiquing an evidence-based approach — harm reduction — which sets the stage for explaining how misunderstanding harm reduction can be harmful (The New York Times).

Similar stories to this likely contributed to a backlash in California, resulting in the overwhelming support for Proposition 36, which increased punishments for some crimes bundled with mandated treatment for drug-related charges. Unfortunately, most voters were likely not aware that the proposition came with no funding (CalMatters).

But that might not be the point. Comparing experience and evidence is hard when people are frustrated. Mothers Against Drug Use and Death may not be arguing about policy details, but they do want a response from San Francisco’s leaders that matches their experience: a rally, a call to action, a state of emergency (ABC 7).

One might assume then that a negative reaction to harm reduction could forewarn a return to the “war on drugs” (BMJ), but hyperbole risks falling on deaf ears. Similarly, an appeal to the president’s potential greatness for solving our drug crisis (The Lancet Psychiatry) likely won’t change hearts or minds. If this didn’t work in 2024, why would it work now?

Going forward, we’ll have to communicate harm reduction (and addiction) differently, whether we like it or not. Case in point, the harms with cannabis use disorder are mounting with each publication: 5-year mortality rates are alarming (JAMA Network Open) and the association with schizophrenia is a growing concern (JAMA Network Open). As an editorial puts it: “It is time to confront this public health crisis head-on,” but when the public confuses medicalization, decriminalization, legalization, and commercialization with harm reduction, then the pendulum is swinging in all the wrong directions (TIME). We can wait for it to correct itself or we can better define and communicate harm reduction for all — otherwise we risk losing the term altogether.

In the meantime, let’s take a look at a good example of how to approach harm reduction: ASAM’s guidance on Engagement and Retention of Nonabstinent Patients in Substance Use Treatment (Journal of Addiction Medicine).

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

ASAM Weekly is looking for a Co-Editor to join the ASAM Weekly Team.

Please click here for details and to apply. 


ASAM Criteria Fourth Edition Assessment Guide

The ASAM Criteria® Fourth Edition Level of Care Assessment Guide, developed by ASAM and pilot tested by UCLA Integrated Substance Use and Addiction Programs (ISAP), is a streamlined tool that helps clinical interviewers collect just enough information to make an appropriate level of care recommendation. The Guide promotes standardized decision-making by helping clinicians apply ASAM’s Dimensional Admission Criteria. It also supports identification of immediate needs and documentation for utilization review. 

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Lead Story 

Cannabis Use Disorder Emergency Department Visits and Hospitalizations and 5-Year Mortality ðŸ”“

JAMA Network Open

This cohort study of 11.6 million people who were studied for a median of five years investigated if individuals who have hospital-based (emergency department or hospitalization) care for a cannabis use disorder (CUD) were at increased risk of death. Researchers found that individuals with incident hospital-based care for a CUD were at a 2.8-fold increased risk of death within five years relative to the general population. These results suggest that individuals who require hospital-based care for a CUD may be at increased risk of premature death.

Research and Science 

Changes in Incident Schizophrenia Diagnoses Associated With Cannabis Use Disorder After Cannabis Legalization🔓  

JAMA Network Open

This population-based cohort study explored whether the liberalization of medical cannabis and the legalization of nonmedical cannabis in Canada were associated with changes in the population-attributable fraction of cannabis use disorders associated with schizophrenia. The study was comprised of 13,588,681 individuals, and the population-attributable fraction of cannabis use disorder associated with schizophrenia increased significantly from 3.7% in the prelegalization period to 10.3% during the postlegalization period. These findings suggest that the association between cannabis use disorders and schizophrenia is an important consideration for the legalization of cannabis.

The Dynorphin/-Opioid Receptor System at the Interface of Hyperalgesia/Hyperkatifeia and Addiction🔓

Current Addiction Reports

Hyperalgesia and hyperkatifeia are two drivers of continued use of opioids in opioid use disorder (OUD). Hyperalgesia in OUD is the development of higher sensitivity to and lower tolerance to painful stimuli, including allodynia, which will occur in withdrawal. Hyperkatifeia is the negative emotional state experienced in withdrawal and includes dysphoria, anxiety, irritability, and emotional pain. The authors review the preclinical evidence of the involvement of dynorphin and kappa-opioid receptor (KOR) systems in pain, negative affect states, and substance use disorders, including noting evidence of sexual dimorphism. The authors propose modulation of the dynorphin/KOR system as a potential and promising target to address hyperalgesia and hyperkatifeia experienced in opioid withdrawal. 

Standardizing research methods for opioid dose comparison: the NIH HEAL morphine milligram equivalent calculator🔓

PAIN

The National Institutes of Health (NIH) Helping to End Addiction Longer-term (HEAL) initiative required data harmonization, including consistent opioid measurements. Previous efforts have developed morphine milligram equivalent (MME) calculations but focused on opioid-related adverse events rather than pain equianalgesia and excluded some opioids used in pain research. In this study, incorporating evidence-based mapping factors from literature, standardized calculation methods were used to develop a new MME calculator encompassing 29 opioids, including previously excluded opioids and additional formulations. The authors also state the need for ongoing validation of the calculator as new data arise, while recognizing MME calculators cannot account for individual patient variability. 

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Avoiding a new US “war on drugs” 

BMJ

Overdose deaths decreased for the first time between August 2023 and August 2024. This may be related to public health interventions, including increased treatment access and community-based naloxone programs. However, due to a perceived decrease in public safety in the last couple of years and a focus on “law and order,” this editorial raises concerns about a return of US drug policy to a criminalization and legal approach, despite evidence that such an approach does not decrease drug taking or overdoses. Further, the authors note law enforcement approaches will exacerbate health and social inequities, disproportionately affecting communities of color, which have seen an increase in overdose deaths compared to White communities. The authors urge a continued focus on and investment in evidence-based public health approaches. 

The biology of addiction 

Science Signaling

It has long been recognized that addiction involves dopaminergic cells in the ventral tegmental area (VTA) that synapse in the nucleus accumbens (NAc), known as the reward circuit. This paper discusses recent research revealing the complexity of this neurobiology. Many of the VTA cell neurons project to regions throughout the brain (dorsal striatum, amygdala, prefrontal cortex, etc.) other than the NAc. The NAc contains cells with D1 dopamine receptors and others with D2 receptors. Cocaine activates the D1 cells and inhibits the D2 cells, while opioids activate both, and these drugs result in similar patterns in the NAc of gene priming and desensitization. Epigenetic mechanisms also modify gene expression and persist long after drug exposure and may play a role in relapse. Nonneuronal brain cells also likely play a role. The complexity of this neurobiology suggests translating the basic science into treatments will be challenging.

Clinical Considerations for Engagement and Retention of Nonabstinent Patients in Care ðŸ”“

Journal of Addiction Medicine

This commentary reviews the ASAM guidance on Engagement and Retention of Nonabstinent Patients in Substance Use Treatment. The first of 10 items in this guidance is to create a welcoming, nonjudgmental, and trauma-sensitive environment that reduces stigma and encourages patients to return. Do not require abstinence for treatment and only administratively discharge patients as a last resort. Follow up with patients who have left care, encouraging them to re-engage in treatment. Cultivate support among staff for these measures and work to retain staff, since interactions with staff are a common reason for patients to self-discharge. Monitor and seek to improve patient engagement and retention.

Trump 2.0: a better way to show leadership🔓

The Lancet Psychiatry

This editorial asks President Trump to focus efforts on mental health issues in the US, specifically in 2 areas. Suicide is a major concern, and most suicides are from firearms. Evidence shows that small changes in gun laws can have a large impact on suicide rates. The authors also suggest drug overdose be addressed by decriminalizing drug use and improving access to opioid agonist treatment, syringe exchanges, and safe supply programs.