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This Week in the ASAM Weekly

Addiction specialists are opinionated people, and rightfully so. It takes a certain level of commitment to consider the scientific merits of fake beer or mocktails while balancing the harms of cue reactivity, liver metabolism, or impacts on pregnancy ().

A certain level of conviction is also necessary, for example, to counter societal fears or political momentum that undermines a good cause. As stated in a commentary from , “2024 will be one of the most consequential years for elections in global history,” so we must protect and expand thoughtful policies of harm reduction. And it takes not only conviction but also expertise to work with policymakers on a global scale. The United Nations Office on Drugs and Crime-World Health Organization Informal Scientific Network (UNODC-WHO ISN) has both of these qualities and more, advising for the most effective prevention and treatment strategies that protect youth all over the world from the negative effects of substance use ().

It shouldn’t be all that surprising then that addiction specialists are also broadly focused. Although we are bending the overdose curve, social determinants of health and systemic racism show us that more needs to be done (). Though sometimes, the most courageous thing we can do is self-reflect. Psychedelic medicine might have swept us off our feet, but now is the time to start asking ourselves how we can really make psychedelic research work ().

Again, addiction specialists are people with opinions, often combined with conviction, courage, expertise, and self-awareness. It’s people like this who make great advocates. So thank you to those who showed up last week for the on Capitol Hill. Advocating is important work, but it can also be lots of fun. 

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 

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JAMA Health Forum

This cross-sectional study examined whether disparities in medication for opioid use disorder (MOUD) treatment between individuals referred by the criminal justice system and other sources has decreased. Analyzing more than 3 million admissions to treatment centers for opioid use disorder between 2014 and 2021, researchers found that although the use of MOUD among people referred to treatment by the criminal justice system has increased, it remains far lower than for people referred by other sources. This disparity exists in most states and is closing slowly. Targeted efforts to increase MOUD use among individuals with opioid use disorder and criminal justice system involvement are needed to address the poor outcomes experienced by this population. 

Research and Science

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The New England Journal of Medicine

The author of this editorial reviews The HEALing Communities study that used multiple interventions to reduce overdose deaths (ASAM Weekly June 25). However, both the study and control groups saw increases in OD deaths. The author discusses several reasons for this discouraging result: COVID interfered with the roll out; the study was underpowered based on an unrealistic expectation of a 40% reduction in OD deaths; the drug supply became increasingly toxic with fentanyl appearing alongside other drugs and in counterfeit pills; and the at-risk population grew to 3.7 million injection drug users, over twice earlier estimates. In a 2018 New York Times article, 30 experts suggested that 100 billion dollars should be spent on medication treatment. Bills were introduced in congress but none of them passed. Now, tens of billions have come from legislation, local funding, and opioid settlements.

Drug and Alcohol Dependence

In 2018, only 3,000 US physicians were certified in addiction medicine, despite over 10 million individuals with SUD. Residency accreditation now requires SUD education in “applicable” specialties such as internal medicine and family medicine. The authors argue that addiction medicine rotations need to be community-based. Health disparities affect the impact of SUDs; for example, older black men have 7 times the OD death rate of their white peers. In addition, many SUD treatment programs take place outside traditional medical settings. Resident physicians often encounter SUD; however, this usually consists of treating complications of advanced SUD. Seeing patients seeking recovery in community settings presents a more optimistic picture of SUDs and should help combat stigma and inherent bias. The authors describe a community SUD rotation they have created in the Chicago area.

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World Psychiatry

Scientists, policymakers, practitioners, and communities must work together to implement the most effective prevention and treatment strategies, policies, and interventions, such as those outlined in the United Nations Office on Drugs and Crime (UNODC) - World Health Organization (WHO) International Standards for Drug Use Prevention and the UNODC-WHO International Standards for Treatment of Drug Use Disorders. The Informal Scientific Network (ISN) recommends that policymakers put evidence-based and ethical policies for adolescent substance use and substance use disorders into practice, with the necessary resources, so that every adolescent can attain the highest level of health.

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Science

Psychedelic-assisted therapy (PAT) may offer promising treatment for mental health disorders, but as noted in this editorial, much additional research is needed. The authors highlight multiple areas of concern in research, including that because of their effects, placebo control trials are difficult, which the authors suggest could be addressed with dose-response designs. Also, research to date has not been conducted in a diverse population, raising concerns about generalizability and issues with confounding as the populations included to date may be prone to expect results. In addition, long-term results are unclear, and interventions are quite variable, specifically regarding variation in therapy delivered with the psychedelics. Unless research can address these issues and other concerns about safety, PAT is unlikely to become a breakthrough therapy.

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Harm Reduction Journal

While Europe has been a leader in harm reduction for substance use disorders, there are significant threats to ongoing efforts. In this commentary, the authors note harm reduction strategies have not been implemented throughout Europe, particularly in eastern Europe, with poor outcomes. In addition, with multiple competing crises, including war, climate change, and other humanitarian disasters, there is less political will to continue and expand these interventions. In this context and with the threat of synthetic opioids, the authors argue that greater effort is needed to respond proactively to expand known effective harm reduction approaches and develop new interventions to address the more dangerous drug supply.

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Preventive Medicine Reports

The WHO reports a marked increase recently in the use of non-alcoholic beverages (NAB). NAB legally contain <0.5% alcohol; however, one study found 29% contained more alcohol than labeled. This study reviewed the response of US doctors on a digital health service to questions about NAB use in certain medical situations and found mixed responses ranging from abstain, to moderate, to no problem. Patients with liver disease have slowed alcohol metabolism, and one case study of a patient with end-stage liver disease found 9 NAB produced a blood alcohol level of 0.06 g/dl. Questions about NAB use during pregnancy and with benzodiazepines also generated responses from abstain to no concern. The authors express concern that cue reactivity could result in increased alcohol use in patients with high-risk alcohol use, and they are interested in how addiction providers advise their patients.

In The News 

Rolling Stone/Yahoo!

The New York Times

The Associated Press

STAT

Reuters

The Conversation