ASAM Weekly November 28, 2023
SAMHSA recently released results from the 2022 National Survey on Drug Use and Health (NSDUH). While further analysis of the data is expected to follow, many of our featured publications this week provide important context for the numbers.
Marijuana continues to be the most commonly used illicit substance in the US, bringing with it unique public health concerns. Researchers from the largest genetic study of cannabis use disorders (CUD) found a potential link between CUD and lung cancer and expanded upon our understanding of psychopathology and cannabis use (Nature Genetics). The CDC published an important yet unfortunate case report on the death of an employee from cannabis-related occupational asthma, and also found evidence of symptoms in other co-workers (MMWR).
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The public often views e-cigarettes and cannabis as safer alternatives to tobacco but as our lead article from Heart Rhythm considers, the harms specifically toward cardiovascular health could be equivalent. In this study, rats were exposed to relatively modest amounts of tobacco, nicotine, and cannabis products over eight weeks and found to have similar pathophysiological changes. Similarly, there is concern that prenatal exposure to cannabis can produce similar maternal and infant outcomes as seen with tobacco. A study representing over 1.2 million Canadian pregnancies found an increased likelihood of preterm birth, low birth weight, small-for-gestational age and congenital anomalies in cannabis-exposed births (Plos One).
Through the lens of the AIDS epidemic, a commentary in the Journal of Addiction Medicine explains how grief and trauma are experienced in the OUD community. The NIAAA turned 50 (in 2020) and Dr. Koob reflects on its history and the significant advances that have been made (Alcohol Research Current Reviews). A comparison of minimally disruptive OUD care with the current state of addiction care shows how much further we can go (Journal of General Internal Medicine), while a study on “secret shoppers” calling local pharmacies to assess buprenorphine capacity shows that we may not have gone as far as we think (Addiction Science & Clinical Practice).
Lastly, 42 CFR Part 2 is overdue for an upgrade. The US Health and Human Services Department has announced several important changes to the law and is welcoming public comment (HHS.gov).
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
This study investigated the cardiovascular effects of exposure to tobacco smoke, vape aerosol, heated tobacco products, marijuana smoke, THC-free marijuana, or air (placebo control). Rats were exposed to a single 5-minute session 5 days a week for 2 months. This exposure was judged to be similar to a single smoking or vaping session a day. Left ventricular dilation and reduction in LV ejection fraction was seen in all non-air groups along with reduction in heart rate variability. Both atrial fibrillation and ventricular tachycardia were more easily induced in all non-air groups. Decrease in microvessel density and severe interstitial fibrosis was seen on histology from all non-air groups. The authors conclude that all tobacco products (including vaping) and marijuana carry substantial risk of cardiac disease.
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
With the recent legalization of cannabis in Canada, this population-based study investigated the effects of prenatal cannabis use on maternal and newborn outcomes, and modification by infant sex. The prevalence of cannabis use in the studied cohort was approximately 2%. Prenatal cannabis use was found to increase the likelihood of preterm birth, low birth weight, small-for-gestational age, and major congenital anomalies with prenatally exposed female infants showing evidence of increased susceptibility. Additional measures are needed to inform the public and providers of the inherent risks of cannabis exposure in pregnancy.
Journal of General Internal Medicine
Although epidemiological studies point to increased risk of acute coronary syndrome (ACS) in opioid users, in-hospital management and outcomes are unknown for this population when presenting with ACS. Using the National Inpatient Sample database, this study found that compared to patients without opioid-related diagnoses (ORD) presenting with ACS, patients with ORD were younger with fewer cardiovascular risk factors. However, in-hospital mortality was higher in patients with ORD presenting with ACS. Patients with ORD were more likely to experience in-hospital cardiac arrest and less likely to undergo angiogram or percutaneous coronary intervention.
Addiction Science & Clinical Practice
This study investigated the availability of buprenorphine products in pharmacies in South Florida. Both outpatient (n=200) and inpatient (n=25) pharmacies were surveyed by telephone. Only 38% of outpatient pharmacies had any buprenorphine in stock and only 55% of those without buprenorphine were willing to order it. There was a significant difference in availability by county, with the least availability in Miami-Dade at 27% and the most in Palm Beach at 47% (p=0.04). More inpatient pharmacies had buprenorphine (88%) but many (55%) had implemented restrictions beyond federal regulations. The most common restriction was to providers of specific specialties. The authors conclude that there are significant pharmacy-related barriers to treatment of OUD.
Drug Science, Policy and Law
The Psychoactive Substance Act (PSA) prospectively banned newly synthesized chemicals with psychoactive effects in the United Kingdom. In this review, the author summarizes changes in sales and mortality due to novel psychoactive substances (NPS), though the author does note significant limitations in the data. While there was a clear decrease in open sales of NPS after the implementation of the PSA, there was a shift to street-level and online sales, which is harder to capture. In addition, while there was an initial decrease in deaths associated with NPS, those numbers increased subsequently, potentially due to an increased potency of NPS. Also of note, while looking specifically at stimulant NPS, there was no decrease in associated deaths, but there was a concurrent increase in deaths due to conventional stimulants.
Journal of General Internal Medicine
Many US health systems and policies produce unwarranted, inflexible, and punitive practices that create life-threatening barriers to care for people struggling with substance use disorders. Minimally disruptive medicine (MDM) is a framework that focuses on achieving patient goals while imposing the smallest possible burden on their lives. A minimally disruptive OUD framework could inform improvements in clinical practice, health system redesign, payment reform, and policy change. That means incorporating factors such as racism, housing, transportation, income, technology, and culture into care.
Alcohol Research Current Reviews
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) was created 50 years ago by an act of Congress with a mission to conduct health education, training, research, and planning programs for the prevention and treatment of alcohol-related problems. In this editorial, the author looks back at some of the accomplishments in those 50 years and references several articles in the Festschrift topic series. Some of the major accomplishments include the epidemiology of alcohol use, genetic basis of alcohol use disorder (AUD), effects of alcohol on adolescent brains, neurobiology in recovery from AUD, behavioral interventions and medications for AUD, effects on the fetus, and finally alcohol-associated liver disease. While these are not all the accomplishments in the last 50 years, they highlight some of the successes of the NIAAA.
Journal of Addiction Medicine
The AIDS epidemic provides a framework for understanding the impact of grief in the opioid overdose crisis. Today, most clinicians do not routinely discuss the impact of overdose losses or consider the role of grief in treatment outcomes with their patients with OUD. This grief places patients at greater risk of returning to use and losing control over their use, resulting in increased risk of overdose or suicide. Direct, tangible measures can be implemented, including the Brief Grief Questionnaire, referral to psychotherapy, or antidepressant medication. Clinicians should also heed worsening OUD by enhancing prevention efforts, titrating medications to control cravings, and employing harm reduction strategies.
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Editor-in-Chief: Nicholas Athanasiou, MD, MBA, DFASAM
Emeritus Editor: William Haning, MD, DFAPA, DFASAM
Publications Chair: Nicholas Athanasiou, MD, MBA, DFASAM
Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
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