ASAM Weekly for November 15, 2022
This Week in the ASAM Weekly
Stigmatizing language has a long history in medical literature. A recent study helps identify the prevalence of stigmatizing terminology in AUD clinical trials, illustrating and encouraging the progress still to be made in our field (Journal of Addiction Medicine). Considering many words were engraved long ago in the names of leading addiction journals and institutions, the American Society of Addiction Medicine and Journal of Addiction Medicine are rather fortunate in their titles.
In 2020, the National Institute on Alcohol Abuse and Alcoholism hosted a 2-day symposium in recognition of its 50th anniversary (Festschrift-2020) and has since published a number of related articles. The most recent is a review and update on alcohol and adaptations in the brain’s stress response system (Alcohol Research: Current Reviews). This piece adds further to our understanding of a substance that is implicated in an estimated 1 in 8 premature deaths in adults (20 to 64 years) and 1 in 5 in young to middle-aged adults (20-49 years) (JAMA Network Open).
Two significant, historical events that highlight the broader challenges of alcohol and drug use are the passage of the Affordable Care Act (ACA) and the COVID-19 pandemic. Although the ACA ushered in a more equitable landscape of substance use treatment, an analysis of NSDUH data indicates that financial reforms were insufficient to address socio-ecological barriers (Drug and Alcohol Dependence Reports). An update on the pandemic’s impact on addictive disorders shows that although population-level data did not show increased use of most substances, the relation between increased mortality and increased use in high-risk groups is telling (Addiction).
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
JAMA Network Open
This cross-sectional study sought to estimate the mean annual number of deaths from excessive alcohol use relative to total deaths among adults 20 to 64 years of age. Alcohol-attributable deaths accounted for an estimated 20.3% of total deaths among adults 20 to 49 years of age. By state, alcohol-attributable deaths ranged from 9.3% of total deaths in Mississippi to a high of 21.7% in New Mexico. Findings suggest that alcohol-attributable deaths were responsible for 1 in 8 deaths among adults 20 to 64 years of age, and 1 in 5 deaths among adults 20 to 49 years of age. The authors suggest that these death rates could be reduced with increased implementation of evidence-based policies, such as increasing alcohol taxes or regulating alcohol outlet density.
Call for Reviewers
The Journal of Addiction Medicine is seeking to expand its cadre of manuscript reviewers. We are seeking reviewers with expertise in the following areas: Stimulants, Psychiatric epidemiology, Qualitative methodology, Genetics, Neurology, Emerging substances, Kratom, Novel Psychoactive Substances, Psychedelics, New pharmaceutical treatments, Toxicology, Criminal justice and addiction medicine, Machine Learning, Pain and Palliative Care, Adolescent Medicine, Maternal Child Health, and Behavioral Addictions. View the full opportunity here.
Research and Science
Journal of Addiction Medicine
The authors performed a search for clinical trials for AUD and 500 were selected at random. Of these, 147 met the inclusion criteria and were screened for the presence of stigmatizing terminology. A total of 117 (78%) contained stigmatizing terminology. Terms frequently found were “drop out” (39%), “relapse” (36%), “adherent” (35%), “compliant” (15%), and “fail” (14%). These results are similar to the use of stigmatizing terminology in articles concerning psoriasis, amputations, and heart failure. The authors call on researchers to use language that reflects patient-centered care.
The American Journal of Psychiatry
Heavy episodic drinking or binge drinking is common, especially among sexual and gender minority individuals. This double-blind placebo-controlled trial tested the effect on binge drinking and alcohol use outcomes of taking oral naltrexone on a targeted basis, i.e., during periods of alcohol craving or when heavy drinking was anticipated. Targeted naltrexone significantly reduced drinking outcomes among SGM with mild to moderate alcohol use disorder during treatment, with sustained effects at 6 months post-treatment. Naltrexone may be an important pharmacotherapy to address binge drinking in populations with mild to moderate alcohol use disorder.
JAMA Network Open
Heavy drinking among young adults is a major public health concern. Brief motivational interventions in the emergency department have shown promising but inconsistent results. In this randomized clinical trial, brief motivational intervention helped study participants maintain a statistically significant lower number of heavy drinking days over one year compared with brief advice. No effects on alcohol-related problems were found. These findings suggest that a brief motivational intervention model implemented in the emergency department among intoxicated young adults can have a beneficial effect on heavy drinking.
Drug and Alcohol Dependence Reports
Utilizing the National Survey on Drug Use and Health (NSDUH), this study assesses changes in substance use disorder (SUD) treatment gaps and barriers pre- and post-implementation of the Affordable Care Act (ACA). The authors found no statistically significant change in past-year treatment gap (needed but not receiving treatment) in the bivariate (93.1 % vs 93.2%) or multivariate analysis (OR 1.11, p=0.13). Among self-reported barriers to treatment, insurance-related barriers did decrease (41.9% vs 35.9%) but were not statistically significant (p=0.08). Of note, stigma (16.8% vs 24.1%, p<0.01) and access-related barriers (31.6% vs 33.4%, p<0.01) increased post-ACA. While the ACA did expand access to insurance, this study highlights that interventions to expand access to care need a multi-pronged approach in addition to health services financing.
The 2022 CDC Clinical Practice Guideline expands guidance for treatment of acute and subacute pain. This updated guideline aims to promote equitable access to effective, informed, individualized, safe pain management that improves function and quality of life, while at the same time reduce the risks associated with opioid use. Several new recommendations are included, such as the consideration of opioid therapy for acute pain only if its benefits are anticipated to outweigh risks. The guideline notes the role of opioid therapy for moderate-to-severe acute pain when NSAIDs and other therapies are contraindicated or unlikely to be suitably effective. Another new recommendation details how clinicians can work with patients receiving opioids in discontinuation strategies.
Alcohol Research: Current Reviews
This article reviews research regarding the relationship between AUD and the neurobiology of stress. Repeated heavy drinking results in increased basal cortisol levels, a change that predicts craving for alcohol. However, the increase in cortisol in response to stress is lower in people who drink heavily compared to moderate drinkers. The authors speculate that alcohol use may serve to augment this reduced cortisol response to stress. Also, the volume of gray matter in the medial prefrontal cortex (involved in regulating emotions) is reduced in those entering treatment and the lowest gray matter volumes were associated with the highest risk of relapse. Alpha-2 adrenergic agonists, such as prazosin, improve prefrontal functioning and reduce alcohol craving. In a study of 100 patients with AUD, prazosin reduced craving suggesting utility in the treatment of AUD.
In this editorial, the authors summarize what occurred across various substance use disorders and gambling during the COVID-19 epidemic. They note that both opioid and alcohol use did not change significantly, but there was an increase in opioid-related overdoses and increases in alcohol-specific mortality. Overall, cannabis use did not increase, but among regular users, frequency and quantity of use increased. There was an increase in both initiation and cessation of tobacco, but notably current and former smokers had increased disease severity with COVID-19 infection. Finally, overall gambling decreased, but there was an increase in online gambling and some turning to day trading. There is limited data about changes in stimulant use and the potential long-term effects are unknown.
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