ASAM Weekly for October 3, 2023
This Week in the ASAM Weekly
Tucked within social determinants of health are commercial determinants which have a particular interest in “addictiveness.” This is clearly evident in the lead article demonstrating how tobacco companies shifted the US food industry towards hyperpalatability beginning in the 1980s (Addiction). More recently, social media companies modernized addictiveness through algorithms that increase engagement with their platforms, but the more adolescents engage with social media, the more susceptible they are to initiating e-cigarette use (Preventing Chronic Disease).
The risks of addiction from opioids were minimized for commercial interests, an opioid crisis followed, and now we are entering a fourth wave (not clearly) defined by “polysubstance use” and rising overdose deaths (The American Journal of Drug and Alcohol Abuse). In response, some states have moved towards decriminalization to reduce deaths and address social determinants of health (JAMA Psychiatry), but time may not be on their political side. Even the mayor of San Francisco is proposing to drug test welfare recipients, framing the problem as one of individual determination (POLITICO).
If addictiveness is a mechanism in which commercial determinants influence or even overwhelm an individual’s determination of health, then would mitigating addiction risk lead to more equitable treatments? That is what is so interesting about a cholinergic circuit that relieves pain without tolerance, reward, or withdrawal (Neuron).
Thanks for reading,
Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief
with Co-Editors: Brandon Aden, MD, MPH, FASAM, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD
Hyper-palatable foods (HPF) contain fat and sodium, fat and simple sugars, and carbohydrate and sodium at specific thresholds to induce hyperpalatability, creating an artificially rewarding experience. This study compared tobacco companies who owned food companies to food companies not owned by tobacco companies, with regard to hyperpalatability between 1988 and 2001. Upon review of industry documents, this study found that tobacco companies “selectively disseminated” HPF into the US market. Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned. As late as 2018, market saturation of fat and sodium HPF was close to 60% and carbohydrate and sodium HPF was almost 20% regardless of tobacco ownership. Further research should consider the links between industries to appreciate potential impact on public health.
Research and Science
Chronic pain is a significant burden for afflicted individuals and society. Although opioids effectively relieve pain, significant adverse outcomes limit their utility and efficacy. The role of central cholinergic signaling in pain modulation remains poorly understood. This study identified an endogenous cholinergic circuit that regulates sensory and affective components of acute and chronic pain. Activating PPTgChAT+ → vlPAG projections exerts profound analgesia through α7 nAChRs that inhibit vlPAGGABA+ neurons to relieve pain despite opioid tolerance. Pain relief through these cholinergic mechanisms was not associated with tolerance, reward, or withdrawal symptoms, highlighting its potential clinical relevance.
Both Oregon and Washington have enacted laws reducing penalties for drug possession. This cohort study investigated whether these laws resulted in fewer fatal drug overdoses one year later. Results reveal that laws decriminalizing drug possession in these states were not associated with changes in fatal drug overdose rates. The average rate difference in Oregon was 0.268 fatal drug overdoses per 100,000, while In Washington, the average rate difference was 0.112 fatal drug overdoses per 100,000. Future research should consider longer-term associations.
Preventing Chronic Disease
In 2022, 95% of adolescents aged 13 to 17 years used social media. Social media platforms have extensive e-cigarette–related content. In general, e-cigarettes are positively portrayed on social media as “glamourous,” “healthy,” and “safe.” This study found that social media use is associated with subsequent susceptibility to e-cigarette use and initiation but not with continued use of e-cigarettes among US adolescents. These findings suggest that understanding and addressing the association between social media and e-cigarette use is critical.
Using national inpatient data between 2004 and 2018, this study examines the association between substance use and cardiovascular (CV) events during pregnancy. During the study period, 1.6% of all deliveries involved substance use, with cannabis and opioids being most common. Any substance use was associated with CV events (aOR 1.61), major cardiac events (aOR 1.53), and maternal mortality (aOR 2.65). Amphetamines/methamphetamines were most strongly associated with any CV event (aOR 2.71), while opioids were most strongly associated with endocarditis (aOR 24.77), alcohol with arrhythmias (aOR 1.68) and cocaine with stroke (aOR 3.75). As substance use has increased during pregnancy, these findings reinforce the importance of maternal health and identifying substance use during pregnancy.
Journal of Addiction Medicine
A national registry of sites providing naltrexone was used to randomly select 10% of the sites for this study. Of the 236 sites contacted, 78 (33%) completed the 11-question survey concerning use of naltrexone in pregnancy. Half of the sites did not accept pregnant patients. Asked if a female patient receiving naltrexone became pregnant, 39% would continue naltrexone and 36% would transition to another medication. Lack of guidelines for use of naltrexone in pregnancy was the most common barrier and some had concerns about pain control during labor and difficulty with naltrexone induction during pregnancy. Preliminary, retrospective, studies support the use of naltrexone in pregnancy. The authors call for large, prospective, randomized trials of naltrexone during pregnancy.
Cannabis withdrawal symptoms include anxiety, sleep disturbance, and anorexia. Previous work has demonstrated that women experience more severe cannabis withdrawal symptoms than men. This study measured blood endocannabinoid (eCB) levels during cannabis abstinence in 5 men and 5 women with cannabis use disorder. During abstinence, the Cannabis Withdrawal Scale (CWS) was greater for women (15.4) than for men (4.5). Of the 7 eCBs measured, one was associated with CWS in both sexes. However, 2 additional eCBs were associated with CWS in females only. Treatments for cannabis use disorder targeting the eCB system need to take these sex differences into account.
The American Journal of Drug and Alcohol Abuse
The term “polysubstance use” has been increasingly used in both research and clinical practice, but there isn’t a clear definition of it. In this prospective, the authors propose what they believe are key components of polysubstance use and need to be clearly defined. These components include: 1) types of substance used, 2) timing of substance use, and 3) the intention for each substance used. Considerations within these categories include number of substances, whether or not the patient meets criteria for substance use disorder, patterns of use, was intentionality of co-use, and if intentional, the motivation. The authors note all these considerations are important both in terms of research and also clinically when considering treatment interventions, and should be clearly defined when discussing polysubstance use.
In The News
The Dallas Morning News