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ASAM Weekly for December 20, 2022
This Week in the ASAM Weekly
Recent years in addiction medicine have been transformative, and this year was exceptional. The opioid crisis and the COVID pandemic, being front-of-mind for many, created a sense of awareness in Washington D.C. that we must continue to capitolize on (spelling pun intended) (NPR, NBC).
Addiction awareness in the news is reaching unofficially unprecedented levels. The NY Times editorial board writes about the beginning of the end for the war on drugs. Juul is settling lawsuits over a teenage vaping crisis that didn’t exist before Juul did (NY Times). The Washington Post has a long list of investigative pieces on addiction with one in particular illustrating the challenges of mixing supply reduction with corruption in Mexico (Washington Post).
The groundswell of medicalization, decriminalization, legalization, and commercialization of substances throughout the US (and globally) will shift our field in many directions. A study from JAMA Network Open found decriminalization of cannabis use can reduce arrests while legalization can do so even further, but more progress is needed to reduce racial disparities. The bi-partisan momentum behind psychedelics is circumventing some of the more traditional gatekeepers so we need to develop a plan for implementation and regulation, quickly (JAMA Psychiatry).
Telehealth for addiction treatment on a large scale has become clinically and politically viable in only a few years, lending to studies on how it can improve treatment retention (Journal of General Internal Medicine). Ethanol substitutes may be part of an emerging wave coming to an emergency department near you (Primary Care Companion).
Lastly, genetics research has always been quite transformative, and our lead study is an example. An incredibly large group of collaborators discovered over 2,300 genes predicting tobacco and alcohol use across a diverse genetic ancestry (Nature).
Happy holidays to all and thank you for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief
with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
This study leverages global genetic diversity across 3.4 million individuals from four major clines of global ancestry to power the discovery and fine-mapping of genomic loci associated with tobacco and alcohol use, to inform function of these loci via ancestry-aware transcriptome-wide association studies, and to evaluate the genetic architecture and predictive power of polygenic risk within and across populations. The authors found that increases in sample size and genetic diversity improved locus identification and fine-mapping resolution, and that a large majority of the associated variants showed consistent effect sizes across ancestry dimensions. However, polygenic risk scores developed in one ancestry performed poorly in others, highlighting the continued need to increase sample sizes of diverse ancestries to realize any potential benefit of polygenic prediction.
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.
The habenula is a relay node between the forebrain and midbrain playing an essential role in making decisions based on the value of choices. Compulsive drug use is attributed to disadvantageous decision-making and has been associated with dysfunction of frontal-midbrain systems. In a rat model of methamphetamine self-administration, addiction-like drug-taking was positively correlated with habenula–frontal cortex and habenula–substantia nigra functional circuit strength. In contrast, drug-taking behavior akin to recreational use negatively correlated with connectivity in these same circuits. These findings suggest that changes within frontal–habenula–midbrain circuits are different in “addicted” versus “recreational use” rats, and these circuits may serve as unique therapeutic targets for individualized treatment of substance use disorders.
JAMA Network Open
More than 30 states have adopted cannabis decriminalization since the 1970s. Recreational cannabis legislation (RCL) has potential to further reduce cannabis possession arrests on top of decriminalization. This cross-sectional study examined whether RCL implementation was associated with a reduction in cannabis possession arrests in states that had already decriminalized cannabis. There was a sizable reduction in cannabis possession arrests among adults in states that had already decriminalized cannabis. RCL did not seem to be associated with changes in arrest rates among youths or disparities in arrest rates. These findings suggest that implementing RCL may be associated with a further reduction in adult arrest rates even after a state decriminalizes cannabis.
Drug and Alcohol Dependence
This study recruited 367 mothers (selected for increased risk of drug use) giving birth between 1994 and 1996. Drug use was determined by biologic screening and/or self-report. Offspring were assessed for externalizing behavior (aggression, rule breaking, delinquency) at age 12, substance use at age 15, and SUD at age 21. Prenatal cocaine exposure (PCE) was present in approximately half of the cases (n=187). Although the relationship between PCE and SUD at age 21 was not statistically significant (p=0.15), two indirect pathways were identified. PCE was associated with externalizing behavior at age 12 (p=0.04) and substance use at age 15 (p=0.01) and both of which in turn were associated with SUD at age 21 (p=0.008 and 0.04 respectively). The authors note these associations could result from genetics and/or life adversity.
The Lancet Gastroenterology and Hepatology
Increased treatment of hepatitis C virus (HCV) among people who inject drugs (PWID) is sorely needed. In this randomized controlled trial, PWID actively injecting within 90 days were randomly assigned to either patient navigation or modified directly observed therapy (mDOT). Adherence was found to be significantly higher in the mDOT group compared to the patient navigation group with no significant difference in sustained virological response (SVR) between the groups. Increased adherence and treatment completion were associated with an increased likelihood of SVR.
In the last few years legislation has been introduced across multiple states to change the legal status of psychedelics, with numbers increasing each year. In this paper, the authors compiled and reviewed 74 bills considered across 25 states between 2019 and 2022. Of the 74 bills considered, 10 were enacted, 32 were rejected and 32 are still under consideration. Most of the bills specifically mention psilocybin (90%) and called for decriminalization (58%), either reducing or eliminating penalties. Among the bills for decriminalization, only 35% called for some training or licensure to prescribe and 23% restricted access to specified treatment centers. Despite the rapid embrace of their potential use in medical treatment, there are still significant questions around their pharmacology and therapeutic efficacy, with policy implications.
The Primary Care Companion For CNS Disorders
This case report describes a ER presentation of a 25-year-old male with presentation suggestive of ethanol intoxication, undetectable blood ethanol and history of use of 2-methyl-2-butanol. Internet sites promote it as a more potent intoxicant than ethanol and it is available from mainstream internet retailers. It is an inhibitor of the GABA-A receptor with a duration of action of 12-24 hours. Intoxication resolved over 3 days in the reported case. It is not metabolized to aldehydes by alcohol dehydrogenase and is not associated with hangover. It is not detected on routine toxicology and appeals to those wishing to evade routine screening. It produces an elevated anion gap causing concern in this case for ingestion of methanol, ethylene glycol, or isopropanol. Use is increasing in Eastern Europe and may rise in the US.
Journal of General Internal Medicine
There are often significant barriers to accessing medication for opioid use disorder (MOUD), including transportation issues or lack of providers in the area. In this study the authors evaluate a virtual-first telehealth opioid use disorder (OUD) treatment platform designed to deliver care without ever requiring in-person visits. 475 patients were enrolled in the program and initiated on buprenorphine, with 69.1% retained in treatment at 180-days. In addition, 31.9% of patients resided in rural areas, with 32% having no x-waivered provider in their zip code. Among those in urban areas, 28% lived in zip codes without providers. While the authors note additional research is needed, telehealth does enable patients to access MOUD care when it may not be available in their area and can decrease transportation barriers.
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Editors & Staff
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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