This Week in the ASAM Weekly

It’s that time again when we present our most-read peer-reviewed scientific publications of the year. Definitions were significant with the NIAAA redefining recovery in AUD (American Journal of Psychiatry) and the conceptualization of pre-addiction made its introduction (JAMA Psychiatry). Treatments for alcohol withdrawal continue to resonate, particularly updates with benzodiazepine-sparing protocols (JAMA Network Open). Research is identifying cannabis as a possible risk factor for dementia (American Journal of Psychiatry) and concern continues to grow around psychotic disorders and potency (The Lancet Psychiatry). 

Polysubstance use was frequently discussed this year and popular with readers in regards to overdose deaths (Journal of Addiction Medicine), co-occurring disorders (American Journal of Psychiatry), and treatments (JAMA Network Open; Drug and Alcohol Dependence). A consequential shift in the narrative around opioid prescribing involved the recognition of overdose and mental health crisis after opioid tapering (JAMA Network Open). 

Lastly, if this time of year has you feeling a little nostalgic, why not fulfill that urge with your very own copy of Treat Addiction - Save Lives: History of the American Society of Addiction Medicine? It tells a wonderful story about the people and the mission behind ASAM. It also makes an amazing gift for that colleague who has everything or the trainee getting ready to go off on their own…but wait, there’s more!

Happy new year and thanks 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

The Top Story of 2022

Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition

The American Journal of Psychiatry

The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from the DSM-5 diagnosis of alcohol use disorder (AUD). This definition views recovery as a process of behavioral change and an outcome, incorporating two key components of recovery: remission from DSM-5 AUD and cessation from heavy drinking, a non-abstinent recovery outcome. It also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing outcomes. By adopting a uniform definition, researchers and health care professionals can more precisely operationalize and measure recovery-related processes.

Most Read Stories of 2022

Outcomes After Implementation of a Benzodiazepine-Sparing Alcohol Withdrawal Order Set in an Integrated Health Care System

JAMA Network Open

Alcohol withdrawal syndrome (AWS) is commonly managed with benzodiazepines (BZD). Adverse effects associated with these drugs have spurred interest in using benzodiazepine-sparing treatments (BZD-S), including clonidine, gabapentin, phenobarbital, thiamine, and valproic acid. This difference-in-difference quality improvement study evaluated revised protocol designed to decrease BZD exposure across 21 community-based hospitals in California, which included 22,899 AWS adult hospitalizations from October 1, 2014, to September 30, 2019. BZD-S order set implementation was associated with a decrease in BZD administration and an increase in use of BZD-S. Favorable trends were noted in outcome measures and statistically significant relative reductions in ICU use and LOS after implementation. 

Long-term Cannabis Users Show Lower Cognitive Reserves and Smaller Hippocampal Volume in Midlife

The American Journal of Psychiatry

Long-term cannabis use may be associated with cognitive deficits and smaller hippocampal volume in midlife, which could thereby increase risk for dementia. This study followed a population-representative birth cohort for five decades, which enabled a comparison of a person’s midlife cognitive abilities to their childhood cognitive abilities before cannabis initiation. Results showed that long-term cannabis users may have diminished cognitive reserves in midlife, and mild cognitive deficits in midlife are associated with increased risk of dementia in later life. Long-term cannabis use might be a modifiable risk factor for dementia.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis

Journal of Addiction Medicine - Editor’s Choice

Overdose deaths continue to be the cause of significant mortality in the US and, while opioids are involved in most overdoses, other substances are frequently involved. In this study, the authors examine overdose records in Maryland to assess the substance involved. While fentanyl was involved in the most overdoses (71%), polysubstance use was found in most deaths (76%). The most frequent patterns of polysubstance use were fentanyl/heroin/cocaine (64%), fentanyl/alcohol (18%) and prescription opioids/benzodiazepines/ antidepressants (18%). Patterns of overdose substance use did vary by demographics and location (Baltimore and outside of Baltimore). Interventions to decrease harms and overdose deaths need to address polysubstance use and should be targeted to patterns of use in geographic regions and populations. 

Alcohol and Cannabis Use Disorders

The American Journal of Psychiatry 

Alcohol and cannabis are among the most commonly used psychoactive substances. A summary of the findings in this issue includes 1) the prevalence of cannabis use and cannabis use disorder in veterans and the factors contributing to use and misuse in this population; 2) an association between cannabis use or cannabis use disorder and self-reported psychotic disorders and the increased prevalence of psychotic disorders conferred by cannabis use; 3) a marked increase in premature mortality in patients with eating disorders who also have substance use disorders; and 4) how alcohol consumption and alcohol-related problems share genetic underpinnings with each other and with alcohol dependence.

Preaddiction—A Missing Concept for Treating Substance Use Disorders 

JAMA Psychiatry

This opinion piece calls for intervention with mild to moderate SUD (as defined by DSM 5) to interrupt the progression to severe SUD. The authors suggest the term preaddiction, similar to the concept of prediabetes. Engaging the public in screening and intervening with prediabetes has succeeded in halting progression. For SUD, existing interventions, such as screening and brief intervention, and computerized cognitive behavioral therapy could be used. However, they expect a range of medications and social support services will also be needed. It will be necessary for medical and nursing schools to teach recognition and management of SUDs and for there to be adequate reimbursement for these interventions. The example of prediabetes demonstrates that an early intervention program can be effective.

Associations of cannabis potency with mental ill health and addiction: a systemic review

The Lancet Psychiatry

Cannabis potency, defined as the concentration of Δ9-tetrahydrocannabinol (THC), has increased internationally, which could increase the risk of adverse health outcomes for cannabis users. This is the first systematic review of the association of cannabis potency with mental health and addiction. Overall, use of higher potency cannabis, relative to lower potency cannabis, was associated with an increased risk of psychosis and cannabis use disorder (CUD). Evidence varied for depression and anxiety. The association of cannabis potency with CUD and psychosis highlights its relevance in health-care settings and for public health guidelines and policies on cannabis sales. Standardization of exposure measures and longitudinal designs are needed to strengthen the evidence of this association.

Comparative Effectiveness Associated With Buprenorphine and Naltrexone in Opioid Use Disorder and Cooccurring Polysubstance Use 

JAMA Network Open

This comparative effectiveness study evaluated 179,280 individuals with opioid use disorder (OUD) using insurance claims. Individuals with OUD and co-occurring substance use disorders (SUDs) were less likely to receive buprenorphine and more likely to receive extended-release naltrexone than peers without polysubstance use; buprenorphine and extended-release naltrexone were comparable in their protective associations with drug- related poisonings in both populations. These findings suggest that individuals with co-occurring SUDs were less likely to receive buprenorphine despite buprenorphine’s association with protecting against overdose in this population.

Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering 

JAMA Network Open

In this cohort study, 19,377 patients experienced opioid dose tapering from 2008 to 2017; this, after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher. The authors hypothesized that tapered patients would have reduced rates of study outcomes during the postinduction period. However, rates of withdrawal, overdose, and mental health crises each increased significantly in the postinduction period. These findings suggest that elevated risks of overdose and mental health crisis may persist for up to 2 years after taper initiation. Patients prescribed higher doses may benefit from more intensive support and monitoring, particularly for depression and suicidality.

Recidivism and mortality after in-jail buprenorphine treatment for opioid use disorder

Drug and Alcohol Dependence

This study examined individuals with OUD in 2 jails in adjacent Massachusetts counties. One jail provided buprenorphine to incarcerated individuals with OUD (n=197) and the other did not (n=272). Individuals were followed for at least 1 year after release and data were collected on recidivism and mortality. Recidivism included re-incarceration, arraignment, or probation violation. Buprenorphine was associated with reduced odds of recidivism (aOR 0.51, p=0.001) overall and of re-incarceration (aOR 0.37, p=0.0001). Mortality in the first year was similar for both groups (around 3%). The researchers conclude these data support provision of buprenorphine for OUD in jail.