反差系列

This Week in the ASAM Weekly

How we frame the problem significantly impacts individuals with addiction. A global review of legislative approaches toward gambling demonstrates how some countries are still warming to a systemic, public health approach while many are mostly focused on vulnerable individuals and promoting responsible gambling (). Such an individual-frame approach would seem almost silly (e.g., “vape responsibly”) if applied to the problem of youth and electronic nicotine delivery systems (ENDS). While regulations are having a hard time keeping up, ENDS manufacturing and social media have made it incredibly convenient for kids to use both cannabis and nicotine ().   

How we fund the solutions also impacts individuals with addiction. Using a system dynamics approach, a study from  demonstrates how funding policies perpetuate inequities for American Indian and Alaska Native communities. Indigenous community-based organizations are oftentimes setup to not succeed because of capability traps, catch 22s, and competition. The study does not speculate on how funding policies breed corruption, but a  article does, as it profiles an Arizona program that funds health care for low-income tribal members and the harms that have come from it. 

On the other hand, there are many examples of when the framing (problem) and funding (solutions) seem aligned. A program in Montana is training “recovery doulas” to help fill a gap in supporting mothers with histories of addiction (). Hancock County in Ohio is using opioid settlement funds to build a comprehensive system focused on both treatment and recovery (). The White House drug czar is even promoting “recovery-friendly” work environments nationwide because financial stability not only supports recovery, but also helps reduce addiction (). 

While we’re talking about correctly framing problems and solutions, why is the US still using the term “drug czar”?

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

Lead 

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The Lancet Public Health

Authors of this article systematically reviewed legislation of jurisdictions that introduced major gambling legislation change (i.e., restricting or extending gambling provision) between Jan 1, 2018, and Dec 31, 2021. More than 80% of countries worldwide now legally permit gambling. Harmful gambling was recognized as a health and wellbeing issue in most of the analyzed jurisdictions, but near-exclusive focus was given to individual-level harms rather than to wider social and economic harms or harms to others. Most of the proposed prevention measures focused on individual responsibility. Gambling policies worldwide are changing, but addressing gambling as a public health issue has not yet translated into comprehensive policy action across jurisdictions.

Research and Science

Drug and Alcohol Dependence

This meta-analysis examined the use of bupropion in the treatment of amphetamine-type stimulant use disorder (ATSUD). A literature search identified eight randomized controlled trials of bupropion in ATSUD with 1,239 participants. The primary outcome measure was reduction in stimulant use verified by urine analysis. Bupropion compared to placebo was associated with a reduction in stimulant use (RR 0.90; 95% CI: 0.84, 0.96), with that reduction greatest when treatment lasted a full 12 weeks (RR 0.85). The study found a statistically significant reduction in stimulant craving at treatment completion. There was no significant effect on treatment retention or severity of depression. The authors described the quality of evidence as “relatively low,” and concluded that this modest (10%) reduction in stimulant use should have the clinical significance verified.
 

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PLOS One

Postmortem blood samples were obtained from opioid overdose decedents in Southern New Jersey between March 2019 and April 2021. The samples from 42 cases (35 male) were sent for expanded toxicological testing. Fentanyl was detected in all but one of the cases, and that case had high levels of methadone, the likely cause of death. Opioids other than fentanyl were found in 38% of cases. Naloxone was present in 19%, suggesting it may have been ineffective. Sedatives were found in 31% and xylazine in 14% of cases respectively. Cocaine was present in 31% and amphetamines in 14%. Evidence of MOUD (buprenorphine or methadone) was present in only 3 (7%) cases. These cases involved multiple substances with few having accessed MOUD.

International Journal of Mental Health and Addiction

This study aimed to assess the association between trauma history and treatment outcomes using registry data. Adolescents and young adults enrolled in treatment for drug use disorders during 2007 to 2018 (n = 6907) were tracked from enrollment to first registered drop-out from substance use disorder treatment, substance-related hospital care, psychiatric care, criminal conviction, and unemployment in the year after treatment enrolment. The impact of trauma exposure in late childhood on associations with outcomes was examined. Physical violence was associated with offending after treatment enrollment and unemployment. Sexual assault and abuse were associated with receiving hospital-based care for psychiatric diagnoses or substance use disorders.

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JAMA Network Open

This qualitative study investigated the use of electronic nicotine delivery systems (ENDS) employed by teens to vape cannabis, powered by the use of YouTube for instructional purposes. Close to one-third of these videos demonstrated modification of ENDS to use cannabis in place of nicotine. Of the 59 videos analyzed, 44% made statements endorsing the health benefits of cannabis, which included treatment of anxiety, depression, attention difficulties, and insomnia. Only roughly one-third of these videos included age restrictions, while nearly half included purchasing links for cannabis products. Of note, FDA regulation of ENDS does not include cannabis products, posing additional concerns that require attention. Finally, misinformation about the health benefits powered by social media may promote dangerous decisions related to health.

JAMA Internal Medicine

In this cluster randomized study, researchers examined the effects of having an opioid use disorder (OUD) nurse care manager in primary care clinic (PC) settings that prescribe buprenorphine and extended-release injectable naltrexone (XR-NTX) for patients with OUD. The study was conducted across 6 health systems in 5 states, each with 2 PCs, one randomized to the intervention. Overall, the interventions groups had 8.2 more patient-years of medication (P=0.002). There was also a greater increase in the percentage of patients who received medication in the intervention group (10.1% to 31.1%) than in the control (16.2% to 19.0%). There was some variation in the impact across the systems, and having broad leadership support and easy pathways to access the nurses were vital to the success.

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Health Affairs

While there have been increases in funding for Indigenous health, the benefits to Indigenous community-based organizations (ICBOs) are limited due to several barriers. One of the biggest challenges is the high burden of obtaining and managing grants, for which ICBOs often don’t have the infrastructure. ICBOs are not part of networks that disseminate funding opportunities, receive little indirect cost relative to larger academic institutions, and thus have limited resources to build that infrastructure. ICBOs also provide traditional psychosocial care based in cultural practices, which are often not covered as direct costs by grants. Potential ways to address these barriers include funding specifically to build that infrastructure, including training of staff for grant management; increasing indirect rates to ICBOs; and redefining direct services to cover cultural practices. 

New England Journal of Medicine

In this perspective, the authors consider FDA draft guidance on psychedelics, issued June 2023. It includes discussion about administration of sub-perceptual doses of psychedelics to promote effective double-blinded studies; guidance on excluding participants with valvular heart disease or pulmonary hypertension from trials (given psychedelics’ high affinity for serotonin 5-hydroxytryptamine 2B receptors); and the inclusion of psychological support such that it could reduce the risk of serious adverse events. If the FDA determines that psychedelics can treat a range of mental health conditions with limited psychological support, it could mimic current recommendations for the treatment of OUD. The authors contend that changes in several areas, including psychological support and adverse-event reporting, will help improve research efforts. 

In The News

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The Washington Post