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This Week in the ASAM Weekly

Defining and diagnosing addiction has evolved over the years with cravings becoming a core component in the conceptualization. As we move forward, machine learning is enabling scientists to identify stable brain patterns that can function as a neuromarker for cravings (food and drugs) and potentially be used in diagnosis and treatment response (). Similarly, white matter tracts (insula-NAc and VTA-NAc) may be used as neuroimaging markers for tracking cravings in individuals with prolonged abstinence from heroin (). 

Ultimately, reducing cravings is fundamental to treating addiction, but further research is needed to better elucidate the interplay between cravings’ impact on MOUD and vice versa ().

For many, awareness about the harms of tobacco use was an introduction to the idea of cravings, while the popularity of ENDS has furthered the awareness toward nicotine addiction. While more efforts are needed to reduce the preventable diseases and deaths from tobacco use (), some interventions can have unintended consequences, especially when considering the tax elasticity and harm reduction potential of ENDS ().

Lastly, since we all crave a good story and addiction has many, some hospitals are using the art of storytelling to help reduce stigma among their staff (). 

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

Lead Story

Nature Neuroscience

Functional MRI images were obtained while subjects were exposed to visual cues for drugs and palatable foods and asked to rate their level of craving. Subjects were individuals who use drugs (cigarette users=21, alcohol users=17, and cocaine users n=21) and matched controls (n=40). Machine learning was used to identify a pattern of neural activation associated with craving, the Neurobiological Craving Signature (NCS), that extended throughout the brain including areas such as the parietal and temporal areas and cerebellum, not usually associated with craving. The same NCS was found for food and drugs indicating the similarity of these cravings. NCS response to drug cues was able to identify individuals who use drugs with an 82% accuracy. The authors suggest that the NCS has promise for diagnosing SUD as well as measuring responses to treatment.

Research and Science

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Drug and Alcohol Dependence

This study included 42 persons with heroin addiction (PHA) and 39 matched healthy controls (HC). Imaging with functional MRI was used to measure fractional anisotropy (FA) of white matter tracts which reflects the health of these tracts. Imaging was performed at baseline and following 8 months of abstinence. At baseline, white matter tracts between the insula and the nucleus accumbens and between the ventral tegmental area and nucleus accumbens were found to have decreased FA in PHA when compared to healthy controls. After 8 months of abstinence, both FA values had improved significantly compared to baseline. Craving (on a 10-point scale) declined significantly during the 8 months of abstinence (6.2 to 1.3, p<0.0001) and correlated with recovery of these white matter tracts.

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Addictive Behaviors

In this systematic review, the authors examine 10 randomized trials to assess impact of buprenorphine on opioid cravings, including in comparison to methadone and extended release-naltrexone (XR-NTX). Buprenorphine (BUP) does decrease cravings relative to placebo and the reduction is greater at higher doses. However, buprenorphine did not appear to decrease cravings as much when compared to both methadone and XR-NTX, particularly in early treatment. The differences in cravings between BUP and XR-NTX did fade over time and the difference in cravings between BUP and methadone also decreased at higher doses. While it is unclear if these cravings have causal relationship with discontinuation of treatment, it may be worth considering the patient’s craving symptoms in treatment selection and the importance of addressing them during early treatment. 

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Translational Psychiatry

Despite the lack of scientific evidence regarding safety of cannabidiol (CBD) during gestation, pregnant women use CBD for a variety of pregnancy-related symptoms including nausea, insomnia, anxiety, and chronic pain. CBD crosses the placenta and alters its very structure, both of which can have a significant impact on pregnancy outcomes. Using C57BL/6J mice, the most widely used inbred strain and the first to have its genome sequenced, this study found female/male sexual divergence in the consequences of in utero CBD exposure on neonates at early developmental ages. This result may be predictive of adult psychopathology and challenges the idea that CBD is a universally safe compound.

Learn More

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Molecular Psychiatry 

This retrospective cohort study investigated whether COVID-19 is associated with increased risk for endocarditis in patients with opioid or stimulant use disorders. Among patients with OUD or cocaine use disorder, COVID-19 was found to be associated with an increased risk of a new diagnosis of endocarditis. The incidence rate of endocarditis among patients with OUD increased from 3.7 in 2011 to 30.1 in 2022 and was similar for patients with cocaine use disorder. The 180-day hospitalization and mortality risk after diagnosis of endocarditis in these SUD patients was 67.5% in patients with COVID-19, compared to 58.7% in those without COVID-19. The results of this study emphasize the need for endocarditis screening and linkage to specialty care for these patients.

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Journal of Studies on Alcohol and Drugs

Patient presentations to the emergency department (ED) for alcohol-involved injury represent a growing public health burden, but their characteristics and sequelae remain understudied. This retrospective cohort study examined mortality rates among ED patients presenting with alcohol-involved injuries and assessed how mortality varied by injury intent and other characteristics. Using statewide, longitudinally-linked ED patient record and mortality data from California, the authors found that alcohol use disorder involved injury presentations to the ED in California are common and associated with high patient mortality burden, which varies by injury intent. Interventions are needed to reduce excess mortality in these patients.

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Journal of Health Economics

Various interventions have been put in place to curb electronic nicotine delivery systems (ENDS) among youth, including purchasing age limits and in some states, taxation. In this study researchers examine the potential impact of taxes on use of ENDS and combustible tobacco products. They found a negative effect on use of ENDS with increasing taxes, most notably among regular users of ENDS. In addition, there was a decrease in reports of ever using ENDS, suggesting a decrease initiation. However, there also appeared to be an increase in use of combustible cigarettes. The authors note, given current evidence that ENDS appear to be less harmful than combustible cigarettes, policy interventions and evaluation should consider unintended consequences that may increase cigarette use and may have overall negative public health impact.  

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JAMA

This viewpoint offers a comprehensive care package of resources to maximize smoking cessation, including strategies at the individual, health system, and population levels. Cessation efforts advising patients to quit at each encounter and offering brief counseling and medications, additional resources, and follow-up should be encouraged. Strict standards for making tobacco ingredients less toxic and appealing, as well as reducing nicotine yield to minimally addictive/nonaddictive levels are additional strategies to support cessation. Seeking approaches to maximize barrier-free delivery of proven cessation therapies through available health systems is also critical. 

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