American Society of Addiciton Medicine

The ASAM Weekly for March 5th, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

Leaders from the National Institutes of Health are calling on researchers to participate in and benefit from the All of Us Research Program, an initiative leveraging big data and technology to bring precision medicine to diverse populations while addressing health disparities and inequities (Nature Medicine). It’s a great endeavor in a country as large and diverse as the United States. 

Health disparities associated with diverse populations include less access to treatment. A study in the Journal of Addiction Medicine found that access to buprenorphine could drop by more than 50% in communities that were less than 95% white. Treatment is also delivered differently in different states. Individuals visiting Florida were 63% more likely to die from an overdose than if they traveled elsewhere, likely the consequence of a decade of overprescribing followed by a increases in exploitative practices within the treatment industry in Florida (Injury Prevention). 

In a country of over 300 million, we’ve unfortunately lost more than 1 million individuals to overdose deaths in the past two decades and there are potentially 40 million more Americans who have been impacted by those deaths. Known as overdose loss survivors, little is known about their experiences which can reverberate as grief, substance use, or even suicidal ideation (AJPH). 

The granular data from All of Us will be as informative and influential as personal narratives but on a much larger scale. An editorial from the Pittsburgh-Post Gazette does a nice job of combining the evidence with personal stories to convey the importance of allowing safe syringe programs in their state.

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

Racial and Ethnic Disparities in Geographic Availability of Buprenorphine

Journal of Addiction Medicine

To identify whether buprenorphine availability equitably meets the needs of diverse populations, this study examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.

Research and Science

The mediating role of loneliness in the relationship between smartphone addiction and subjective well-being 🔓

Scientific Reports

In this study, the authors evaluated associations with subjective well-being in persons 17-40 enrolled in universities, including urban or rural background, income, gender, smartphone addiction, and loneliness. They found urban students (P<0.001) and higher-income students (P< 0.001) reported higher well-being scores. In addition, smartphone addiction was negatively associated with well-being and positively associated with increased loneliness. In subsequent analysis, loneliness was negatively associated with well-being and partially mediated the negative association between smartphone addiction and well-being. The authors suggest that in addition to interventions to address smartphone addiction, strategies to increase social support could also mitigate some of the negative effects on well-being.

Economic evaluations of establishing opioid overdose prevention centers in 12 North American cities: a systematic review 🔓

Value in Health

Overdose prevention centers (OPCs) are sites where persons can consume previously acquired drugs with supervision in case of overdose; they have been operating in Western Europe and Australia but are limited in North America. In this systematic review, the authors include 16 economic evaluations of OPCs published between 2007 and 2022 that reported cost-effectiveness, cost-benefit, or cost offsets. Assessing for various health outcomes, including HIV, HCV, and overdoses, the studies found OPCs to be cost-effective based on willingness to pay in the US and Canada. In addition, the cost-benefits were >1, supporting greater benefit than cost. While additional studies are needed, particularly given increasing overdose deaths and limited municipalities evaluated, the study provides economic support for the public health benefit of OPCs.

Elevated drug overdose mortality among Americans who visit Florida, 2003–2020 

Injury Prevention 

This study compared the proportion of deaths due to overdose for out-of-state visitors to Florida compared to Florida residents. From 2003 to 2011, overdose deaths were 72% higher for visitors than for Florida residents. During this period, “pill mills” in Florida attracted out-of-state visits to obtain prescription medications. Visitors and residents had similar OD death rates in 2012 following legislation targeting overprescribing. In 2014, Federal law mandated insurance coverage for SUDs. From 2014 to 2020, overdose deaths were 54% higher for visitors. They were recruited by a proliferation of treatment centers engaged in fraudulent overbilling for poor quality or non-existent services. Relapses were an opportunity for readmission and further exploitation (the “Florida Shuffle”). The authors conclude that these events in Florida resulted in overdose deaths of people who live in other parts of the US. 

The dopamine 3 receptor as a candidate biomarker and therapeutic for opioid use disorder 🔓

Addiction Biology 

This article discusses the role that dopamine receptor type D3 plays in opioid use disorder (OUD). The presynaptic D3 receptors (D3R) on dopaminergic neurons inhibit dopamine release when dopamine levels rise in the synaptic cleft, providing negative feedback on dopamine release. Several variants of the gene encoding the D3R have been found to be associated with risk for OUD or early onset of heroin dependence. The authors hypothesize that these variants result in impaired function of the presynaptic D3R, resulting in enhanced opioid-induced dopamine release. Partial agonists at the D3R could restore this negative feedback and are currently being investigated for use in the treatment of OUD. The authors also suggest that the D3R gene variants could provide a diagnostic tool for assessing OUD risk.

Learn More

The All of Us Research Program is an opportunity to enhance the diversity of US biomedical research 🔓

Nature Medicine

Several countries with national health systems have established large, longitudinal cohorts to advance population and precision health, each with unique features and populations, including the UK Biobank and several more. The USA is different from those countries: not only does it lack a national health system for its citizens, but it ranks 43rd in the world for life expectancy. The lack of diversity in genomics research, with more than 90% of studies from populations of European ancestry, has led to many challenges in equity, including non-transportability of polygenic risk scores to different populations and incorrect assignment of genomic variant pathogenicity. All of Us aims to unite the entirety of the NIH toward creating a multimodal, comprehensive assessment of human health that is reflective of the USA.

An Overlooked Emergency: More Than One in Eight US Adults Have Had Their Lives Disrupted by Drug Overdose Deaths 

AJPH 

In a Rand survey, 42% of US adults indicated they knew at least one person who died of overdose. This percentage was considerably higher among people who use drugs; on average they knew 2.9 people who died of overdose. Overdose loss was more common among women, the married, US citizens (versus immigrants), and in New England and the South Central states (KY, TN, MS, AL). When asked about the impact of these overdoses on their lives, 13% of US adults said it disrupted their life and for 4% of US adults the impact was significant or devastating. Studies have shown that such traumatic bereavement has adverse impacts on physical health, mental health, and substance use. The authors call for research on the impact of overdose loss in order to meet the needs of overdose survivors. 

Apologizing for the Alcohol Industry? A Comment on ISFAR's Defense of Alcohol's Purported Health Benefits 🔓

Journal of Studies on Alcohol and Drugs

A critical systematic review and meta-analysis (SRMA) on alcohol use and ischemic heart disease (IHD) risk estimated a nonsignificant degree of protection at up to just one drink per day. This estimate, if incorporated, would likely have led to at least a doubling of the 2020 Global Burden of Disease (GBD) Collaborators’ estimate of alcohol's contribution to premature mortality. The International Scientific Forum on Alcohol Research (ISFAR), a group with long-standing and continuing associations with the alcohol industry, predictably issued a long critique of the recent SRMA of alcohol use and all-cause mortality. They suggest that collective biases led to the creation of controversy and to questioning the issue of moderate alcohol use and health. The authors address their main charges and provide a detailed point-by-point response to their critique in an online supplement.