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The ASAM Weekly for January 9, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

Several of our publications this week address the economics of addiction - supply, demand, and resources. 

A new Senate report is raising awareness about the rising occurrence of opioid overdoses in older Americans, calling it a silent epidemic while often framing it as an issue of border security and supply reduction (Senate.gov). Dr. Cara Poland discusses the importance of demand reduction with alcohol excise taxes, a cost-effective intervention that could raise billions in funding for addiction treatment (STAT News). Writer Jeneen Interlandi continues with a concise assessment of workforce shortages, methadone access laws, and the criminal justice system (NY Times). 

A commentary from Substance Use and Addiction Journal goes further and lays out an eight-point plan for recruiting and retaining the diverse workforce needed to maintain an adequate addiction treatment infrastructure. It will require an increase in much-needed resources, which could come from opioid settlement funds. 

But where there are resources, there are opportunists. Many private companies are pitching their products to local governments that have access to settlement funds, e.g., Wrap Technologies and its lasso-like BolaWrap (MedPage). Cannabis companies are taking one from the pharma playbook by promoting their products as treatments to consumers and offering more than free pens and lunches to physicians (STAT News).

Finding the right balance between supply, demand, and resources is not always straightforward. As the FDA and expert organizations focus on developing guidelines for reducing demand from long-term benzodiazepine use, a comparative-effectiveness study of over 350,000 patients found that discontinuation was associated with a small absolute increase in mortality and other harms (JAMA Network Open). Unfortunately, discontinuing benzodiazepines - like opioids - is not as straightforward as starting them.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM, Jack Woodside, MD, John A. Fromson, MD

Lead Story 


Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy ðŸ”“ 

JAMA Network Open

In this comparative effectiveness study among 353,576 patients receiving stable long-term treatment with benzodiazepines, discontinuation was associated with small absolute increases in mortality and other potential harms, including nonfatal overdose, suicide attempt, suicidal ideation, and emergency department visits. These results suggest benzodiazepine discontinuation among patients prescribed for stable long-term treatment may be associated with unanticipated harms, and that efforts to promote discontinuation should carefully consider the potential risks of discontinuation relative to continuation.

Research and Science 

A systematic review and meta-analysis of neuromodulation therapies for substance use disorders ðŸ”“

Neuropsychopharmacology

This systematic literature search evaluated the efficacy of neuromodulation (NM) to improve behavioral outcomes in substance use disorders (SUDs). Meta-analyses were performed for alcohol and tobacco studies using magnetic stimulation (rTMS) and direct current stimulation (tDCS). The authors found that rTMS reduced substance use and craving. Results were most encouraging when multiple stimulation sessions were applied and the left dorsolateral prefrontal cortex (DLPFC) was targeted. tDCS also produced medium effect sizes for drug use and craving, though they were highly variable and less robust than rTMS; right anodal DLPFC stimulation appeared to be most efficacious. Deep brain stimulation (DBS) studies were typically small, uncontrolled studies, but showed promise in reducing misuse of multiple substances. NM may be promising for the treatment of SUDs.

Preliminary evidence that ketamine alters anterior cingulate resting-state functional connectivity in depressed individuals ðŸ”“

Translational Psychiatry

Ketamine’s effect on activity in the anterior cingulate cortex (ACC) is known to be important relative to its effect on depression and anhedonia. This study used functional MRI to measure the effect of ketamine on activity in 3 subregions of the ACC in patients with treatment resistant depression (n=29) and healthy volunteers (n=21). Patients received an infusion of either ketamine or placebo (randomized and double-blind) and 2 days later completed scales measuring depression and anhedonia. Changes in the perigenual ACC region correlated with improvements in depression, whereas changes in another ACC region, subgenual ACC, correlated with improvements in anhedonia. The authors conclude that attention to ACC subregions is necessary to understand ketamine’s effects.

Which substances pose the greatest risk of substance use disorder after controlling for polysubstance use?

Addiction Research and Theory 

This study estimates the association of use of various substances with the risk of a SUD for that substance. A secondary analysis of data from the 2021 National Survey on Drug Use and Health examined prevalence and frequency of use and criteria for SUD for 8 substances (alcohol, cannabis, cocaine, heroin, hallucinogens, inhalants, methamphetamine, and opiates). Heroin and methamphetamine were found to have the highest risk for SUD for that substance. The lowest risk for SUD was for use of hallucinogens and inhalants. Alcohol and cannabis were the most frequently used substances and were associated with an intermediate risk of SUD (usually of milder severity). The authors conclude that certain substances have a greater association with SUD. 

Learn More

Teen drug use remains below pre-pandemic levels

Michigan News, University of Michigan

The annual Monitoring the Future survey of 8th, 10th, and 12th graders found that overall reported use of illicit substances among teens has remained steady in 2023 compared to 2022 and is still below pre-pandemic levels. In particular, cannabis and non-cannabis illicit drug use remained stable, while alcohol use actually decreased for 12th graders and nicotine vaping decreased for 10th and 12th graders. Despite reported levels of use remaining below pre-COVID levels, overdose deaths have continued to increase. 

Cannabis-Related Disorders and Toxic Effects

The New England Journal of Medicine

In this review, Dr. David Gorelick discusses cannabis intoxication, subacute and long-term effects, withdrawal, and cannabis use disorder (CUD). Cannabis is one of the most used substances globally, with 18.7% of the US population reporting past-year use in 2021. Genetic factors account for about half of the risk of developing CUD, but frequency and duration of use are also significant risk factors, and potency is less clearly linked to risk; notably, potency has doubled in the last 20 years. The authors note recommendations to screen for CUD in health care settings and the primary treatments are cognitive behavioral therapy and motivational enhancement therapy, while the role of medications is primarily to treat symptoms of withdrawal. 

Recruiting and Retaining a Diverse and Skilled Addiction Treatment Workforce

Substance Use and Addiction Journal

While approximately 20 million people have a substance use disorder, only a small percent receive treatment, and this is partially due to the significant shortages in the treatment workforce. The authors make 8 recommendations to address this shortage, particularly to recruit and retain persons from underrepresented minorities. Measures they recommend include equitable hiring, providing supportive training, improving employee well-being, and promoting professional growth. They also support sustainable funding for addiction training for physicians, nurses, social workers, psychologists, and advanced practitioners. Addressing compensation for the workforce is also important as compensation is often lower than for other specialties. 

An overlooked relationship in recovery from substance use disorders: Associations between body mass index and negative emotional states

Physiology and Behavior

Recovery from substance use disorders (SUD) is multifactorial. Being overweight could negatively impact physiological and psychological health-related parameters. Using model selection, this study examined associations between body mass index (BMI) and negative emotional states (NES, e.g., stress, anxiety, depression) in 54 men with SUD and under treatment in five different therapeutic recovery centers. It found that BMI was positively associated with stress (p < .001), anxiety (p < .001), and depression (p = .002). Therefore, these findings suggest that decreasing the accumulation of body fat might contribute to improving mental health in individuals with SUD during recovery.