Â鶹´«Ã½

This Week in the ASAM Weekly

It can be a challenge for clinicians to be the catalyst for healthy behavioral change in people, especially at the population level. That’s one reason why a special report from the International Agency for Research on Cancer is timely: reducing the incidence of cancer will depend on a reduction in alcohol consumption which requires a thoughtful assessment of alcohol policy interventions (). 

It can also be a challenge to encourage people to be healthy on an individual level. Maybe that’s why a case vignette on alcohol use makes a straightforward recommendation: start with an advice-based intervention — not counseling or a motivational-based intervention — while fostering a nonjudgemental and optimistic approach ().

Now, it can be particularly challenging to encourage adolescents to do just about anything, on any level, partly due to the nature of adolescence but also to the nature of prevention science. It’s hard to measure a preventive intervention —whether universal or selective — when the outcome doesn’t happen often enough ().

There are times, however, when an intervention happens so often and so broadly that it too becomes hard to measure (). Social media, for example, has influenced Gen Z to drink less, and many think this is likely due to a fear of getting drunk and going viral (). But what if it's more likely that social media created a preventive, universal intervention that reduced alcohol use through increased awareness? 

Then finding a risk with more universal appeal has the potential to reduce substance use even further. How about the straightforward risk of getting old? It’s a (cellular) fact that substance use leads to old age, specifically in the brain (), and the last thing anyone on social media wants to do is get old. 

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM; John A. Fromson, MD; Jack Woodside, MD

Lead Story 

New England Journal of Medicine

In 2020, alcohol use was responsible for over 740,000 new cancer cases worldwide. In response, The International Agency for Research on Cancer (IARC) released a two-part handbook assessing the effectiveness of public policy measures in reducing alcohol-related cancer risk. The report found that reducing or stopping alcohol consumption lowers the risk of certain cancers and that several policy interventions, such as increasing alcohol taxes; setting minimum pricing; restricting sales by time, place, and age; implementing total sales bans; and enacting strong marketing restrictions, effectively reduce alcohol consumption. Government-run alcohol monopolies and coordinated national strategies were also associated with decreased use. However, bans on alcohol discounts produced inconsistent results. These findings align with the WHO’s Global Alcohol Action Plan and SAFER initiative, highlighting the importance of targeted, enforceable strategies to reduce alcohol-related harm globally. 

Research and Science

 ðŸ”“

The Lancet Public Health

This study from Canada compared patients starting opioid agonist treatment (OAT) with methadone with those starting a safer opioid supply (SOS) program. The SOS program prescribed short-acting opioids, such as hydromorphone, to protect patients from the uncertain potency and contaminants of the illicit opioid supply. Patients on the SOS program had significant reductions in opioid toxicities, ER visits, and hospitalizations compared to before the program. Patients started on methadone had greater reductions in these outcomes. Compared to methadone patients, SOS patients had greater hazard of opioid toxicity (HR=2.8), ER visits (HR=1.6), and hospitalizations (HR=1.5); however, methadone patients left treatment earlier than SOS patients (106 vs 268 days). Correcting for treatment duration, the only significant hazard difference was opioid toxicity (HR = 1.7). The authors conclude that both OAT and SOS programs play a complementary role.  

&²Ô²ú²õ±è;🔓

Sensors

The authors describe previous methods of monitoring MOUD adherence involving smart pill bottles and earbuds that detect swallowing. This study uses smartwatches to detect the gestures associated with taking sublingual buprenorphine or liquid methadone. Accelerometer and gyroscopic data were recorded by the smartwatch while volunteers simulated taking MOUD and daily living tasks. Machine learning processing was used to identify medication-taking gestures. The similarity of methadone and buprenorphine gestures led to occasional misclassification; however, distinguishing between either medication gesture and daily activities was much more accurate. The authors note that this adherence data could be uploaded in real time to the EHR and made available to clinicians, and they suggest that using other smartwatch sensors (pulse, O2sat, time, GPS location) could improve accuracy. 

&²Ô²ú²õ±è;🔓

PLOS Digital Health

In the ongoing opioid epidemic, real-time understanding of shifts in usage patterns across a diverse population are needed to inform policy and public health response. As traditional survey data often have significant time delays, social media platforms are a potential source of real-time data. Prior studies have used some online platforms, but corporate policy shifts can limit accessibility of data. The authors assess 71 platforms based on drug-related discussion, geolocatability, and data accessibility to identify platforms most promising for surveillance. They developed a list of 11 platforms as potential resources while highlighting Facebook, YouTube, TikTok, and LinkedIn as underutilized potential resources. 

Journal of Women’s Health

Pregnant and postpartum individuals with opioid use disorder (OUD) face significant barriers to care, despite increased funding and access to treatment. Legal ambiguities in the Comprehensive Addiction and Recovery Act (CARA) have led some states to penalize patients using prescribed medications for OUD (mOUD), often resulting in child welfare investigations and custody loss. These punitive approaches deter individuals from seeking prenatal care or continuing treatment, increasing health risks for both parent and infant, and disproportionately affecting marginalized populations. Urgent reforms are needed to protect those following evidence-based care, including clearer legal definitions, reduced reliance on toxicology tests, supportive Plans of Safe Care, dual-track reporting systems, expanded federal support, and mandatory provider training.

Learn More 

New England Journal of Medicine

Between 20% and 30% of patients presenting for outpatient care have unhealthy alcohol use, including risky use and alcohol use disorder (AUD), but only 17.4% of adults who drink have discussed this with their clinician and only 2.1% of clinicians use validated screening instruments. In this clinical practice paper, the author provides guidelines to address alcohol use including annual screening of adults for unhealthy alcohol use, providing brief behavioral counseling, and offering treatment. Treatment guidelines for AUD include medications, counseling, and peer support. Medications for AUD include naltrexone and first-line and second-line choices include acamprosate, gabapentin, topiramate, disulfiram, and baclofen. Psychosocial interventions should be provided based on patient preference and availability.  

🔓&²Ô²ú²õ±è;

The American Journal of Psychiatry

In this editorial, the author discusses the Co-Venture trial, a cluster-randomized trial, which provided two 90-minute in-school workshops in 7th grade with the goal of decreasing future substance use disorder (SUD). In the original study, researchers found a 21% reduction in odds of SUD at 5 years of follow-up, as well as a reduction in depression, anxiety, and peer problems. The author does raise questions about potential issues with the intervention, including scalability. In addition, this intervention is provided to a focused group of students who are identified to be at-risk, but the author references another web-based universal intervention with similar outcomes. The author notes the findings from these different studies provide schools with choices about potential interventions.  

 ðŸ”“

Genomic Psychiatry

The study by Kluwe-Schiavon et al. investigates how substance use disorders (SUDs) accelerate brain aging at the molecular level, focusing on the dorsolateral prefrontal cortex, a key area for decision-making. Using postmortem brain tissue, the researchers discovered that addiction causes significant biological aging, marked by changes in mitochondrial function, inflammation, and gene expression. These effects vary across different substances, highlighting the unique biological impact of each drug. The study challenges the traditional view of addiction by emphasizing its neurobiological consequences, urging a shift in how SUDs are understood and treated, and suggests the need for new treatment strategies, including biomarker-based diagnostics and anti-aging therapies, to address the accelerated brain aging seen in individuals with addiction. 

In the News 

Boston Magazine 

🔓

AMA Journal of Ethics

The New York Times

🔓

Cronkite News

🔓

Forbes

STAT

🔓

The Conversation