American Society of Addiciton Medicine

The ASAM Weekly for March 12th, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

“The War on Recovery” is a multi-part, year-long investigation into how the US makes it difficult to obtain medications for OUD. In this first installment, STAT News brings into focus the often absurd barriers that individuals with and those treating OUD face from many directions, with important take-homes such as the contrasting ease of obtaining medication for abortion and an estimation by Dr. Nora Volkow (along with a Q&A) that we could reduce overdose deaths by half, or more.

A common theme from the above investigation is that America views addiction differently than other illnesses, and not always consistently. The harms from tobacco use are well documented and accepted, but how those harms confounded data on cannabis use had left the issue open to debate -- until now. A study from the Journal of the American Heart Association demonstrates that smoking- nicotine or THC -- is bad for the heart.

Part of the concern surrounding the above study is that social perceptions around cannabis use and a growing global market (Forbes) will put many in harm's way. The same is true with alcohol. Data recently released by the CDC demonstrate that alcohol-related deaths jumped almost 30% in five years, likely attributed to the isolation during COVID but also to the accessibility of alcohol and an “acceptability” around binge drinking (PBS). 

There are, however, other perceptions around addiction that are changing for the better. Some politicians see the recovery movement as a “sleeping giant” -- one that should be acknowledged and embraced as a part of American life (NY Times). The federal government is directing funds towards rural communities where many may have felt forgotten during the opioid epidemic (HHS). Even research on oxytocin could shed light on social behavior and opioid use, through anxiolytic modulation via the μ−opioid receptor (Translational Psychiatry).

When the evidence about what ails addiction in America contrasts with what we as a society are doing about it, it might feel our problems are self-inflicted, but they aren’t necessarily. Rather, they are a collection of many choices -- good and bad -- which are rarely straightforward. Take for example deprescribing of benzodiazepines; a persuasive editorial from the American Journal of Psychiatry re-sets the pendulum around the risks of benzodiazepine prescribing. It does not, however, change the fact that learning how to appropriately prescribe benzodiazepines is still not so straightforward. 

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

Association of Cannabis Use With Cardiovascular Outcomes Among US Adults 🔓

Journal of the American Heart Association

Cannabis use has increased in the US and perceived harmfulness has decreased, but there is evidence to suggest that cannabis use may increase risk of cardiovascular disease. In this study, the authors utilized the Brief Risk Factor Surveillance System survey to assess association between cannabis use and cardiovascular disease. In a multivariate analysis, they found an association between daily cannabis use and myocardial infarction (MI) (aOR=1.25) and stroke (aOR=1.42). Among adults who had never smoked cigarettes, the association was even greater for MI (aOR=1.49) and stroke (aOR=2.16). While additional research is needed, these findings suggest cannabis may be a risk for cardiovascular disease, independent of cigarette use.

Research and Science

Pattern of Risks for Psychiatric and Substance Use Disorders in the Offspring of Parents With Alcohol Use Disorder

American Journal of Psychiatry

This study sought to clarify the components of the familial liability to alcohol use disorder (AUD) by examining parent-offspring transmission in a large Swedish population sample with a mean age at follow-up of 37.7 years. The hazard ratio for the offspring was highest for AUD followed by drug use disorder, attention deficit hyperactivity disorder, major depression, and anxiety disorder. All risks for offspring having two parents with AUD were higher than those having one parent with AUD, but the increase with two parents with AUD was greatest for AUD, followed by drug use disorder and attention deficit hyperactivity disorder. Age at AUD onset of the parents predicted risk among the offspring more strongly for AUD and drug use disorder, followed by attention deficit hyperactivity disorder, and then major depression and anxiety disorders.

Healthcare provider perspectives on emergency department-initiated buprenorphine/naloxone: a qualitative study 🔓

BMJ Health Services Research 

Emergency departments (ED) provide a prime opportunity to intervene with patients with opioid use disorder (OUD). This qualitative study assessed ED healthcare workers’ perceptions around providing take-home buprenorphine in EDs. While many of the ED healthcare workers recognized the importance of EDs as a first point of contact and supported the idea of initiating buprenorphine, they did also identify barriers. One significant barrier was time and space, particularly when the ED is busy with a high volume of patients. The other potential barrier was also a potential facilitator - provider familiarity with buprenorphine. The final barriers were patient-related, including willingness to start treatment and to wait in ED to start medication. The authors note these findings support ongoing training for providers and additional support to address time and space availability to increase buprenorphine initiation in EDs. 

A Nationwide Survey Study of Recovery Community Centers Supporting People in Recovery From Substance Use Disorder

Journal of Addiction Medicine

This paper reported on a survey about the operation and services of 198 recovery community centers (RCC) in 39 states. There is rapid growth in RCCs with over half less than 5 years old. Typical services provided by RCCs are recovery support groups (89% of RCCs), naloxone training (84%), employment assistance (72%), housing assistance (64%), recreational/social activities (82%), and volunteer opportunities (89%). Services are primarily peer-led rather than professional. There is an average of 9 paid and 10 volunteer staff. Using a 1 to 5 scale of openness to MOUD, RCCs scored 4.6 with 68% saying they were “extremely open” and 46% advocating that people use MOUD. In summary, RCCs provide services, information, and social interaction, and are welcoming to people who use MOUDs.

Nine-Year Substance Use Treatment Outcomes with Buprenorphine for Opioid Use Disorder in a Federally Qualified Health Center

Drug and Alcohol Dependence

This study described patients (n=1451) who received buprenorphine at a federally- qualified health center in Connecticut from 2007-2016. In addition to MOUD, patients also received primary care medical treatment. The authors suggest this integrated approach would improve treatment retention. Treatment retention at 6 months was 58% and 52% at 1 year. Of the 169 patients followed for the full 9 years, 66% were retained in treatment. Average duration of buprenorphine treatment was 2.26 years. Patients experienced gaps in treatment on average of 1.0 gaps/patient/year with an average gap duration of 17.7 days. Patients were not in a gap and receiving MOUD 81% of the time. Older age and having diabetes were associated with increased retention. The authors conclude that MOUD treatment was successful in this setting and that gaps in treatment are common and reflect the relapsing nature of OUD.





Learn More

Setting the Record Straight on Long-Term Use, Dose Escalation, and Potential Misuse of Prescription Benzodiazepines 🔓

The American Journal of Psychiatry

This editorial accompanies a study elsewhere in the issue reporting that benzodiazepines are infrequently associated with long-term use and dose escalation. The authors note that while benzodiazepines have side effects such as sedation and “mild physiologic dependence,” an “anti-benzodiazepine movement” has caused fear and stigma about their use. They suggest that studies demonstrating adverse effects of these medications have failed to control for confounding conditions that are responsible for the adverse events. As an example, they cite the concern about hip fractures with benzodiazepines. They state that benzodiazepines are effective and safe when “prescribed to patients who are not substance abusers.”

µ-Opioid receptor antagonism facilitates the anxiolytic-like effect of oxytocin in mice 🔓

Translational Psychiatry

Neuropeptides, such as oxytocin and opioid peptides, are important for emotion regulation. Previous studies have demonstrated that oxytocin reduced depression- and anxiety-like behavior in male and female mice, and opioid receptor activation reduced depression-like behavior. This study hypothesized that opioid receptor blockade would inhibit the anxiolytic- and antidepressant-like effects of oxytocin. However, naloxone potentiated the anxiolytic-like, but not the antidepressant-like, effect of oxytocin. The study demonstrated that μ−opioid receptor blockade potentiated the anxiolytic-like effect of oxytocin, whereas κ−opioid receptor blockade inhibited the oxytocin-induced anxiolytic-like effects. The results suggest that endogenous opioids can regulate the oxytocin system to modulate anxiety-like behavior.

“I want to stay here”: Patient and Staff Perspectives on Transitioning from a Low-Threshold Buprenorphine Program to Clinic-Based Care 

Drug and Alcohol Dependence

In this qualitative study, the authors evaluated why patients at a low-threshold buprenorphine program in Baltimore designed to engage marginalized populations in treatment and then transition to longer-term programs were staying at the program rather than transfer. At this program, <10% of patients were transitioning to clinic-based buprenorphine treatment and in interviews patients conveyed they wished to stay in the program because the program conveyed respect for the patient and for continuity of care. In addition, there was a perception that other care programs were more punitive and rigid. Given limited resources of this low-threshold program and patients preference to stay, they could not always accommodate new patients. These findings support expanding low-threshold programs and improving their sustainability.