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This Week in the ASAM Weekly

Let’s be honest, this might not be the year to talk about politics at the Thanksgiving table. That’s why the ASAM Weekly has come up with some Turkey Day Conversation Starters for the addiction specialist. This year's topic - harm reduction. 

First, it’s always best to start with something light and relevant for most people, like technology addiction. From the kids to the grandparents, everyone seems to have their own personal experience with tech, so you can start off by asking, do we have a right to freedom from addictive technology ()?

In response, someone might profess free-will or individual determination (like the child who bargains for five more minutes on your phone), but an astute guest could articulate the similarities between Big Tech and Big Tobacco. They might even remark on the exemplary public health response that reduced rates of tobacco use while underscoring the persistent disparities discussed in a recent . Things are off to a good start. 

While your guests enjoy a feeling of initial agreement over the harms of tobacco, you can enhance the moment with the point that schools are a great place to educate kids about opioid-related harms (). Most everyone should also agree that recent reductions in alcohol-related DUIs are a good thing, but the neighbor stopping by to say “Hi” might imply that a concurrent increase in cannabis-related DUIs is nothing to worry about - according to the guy at his dispensary (). Be patient, the neighbor is just stopping by.

This might be a good time to bring out dessert and transition toward a discussion around Dr. Volkow’s recent blog about the benefits of syringe services programs (). Don’t be surprised if some of your guests take a different tone this year (“they encourage more drug use,” “increase crime,” or “syringes everywhere”), just stick to the evidence and repeat the message: harm reduction helps people who use drugs (). 

Now that you’ve wowed them (or not), you should call it a night. Thank your guests for a wonderful evening of harm reduction and turkey as you say your goodbyes. Inevitably, someone will think you said “harm reduction turkey” and ask if that’s why it was so dry this year…

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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Harm Reduction Journal

This article examines the overlap between gender and substance use in France in the context of institutional care, intimate partner relationships, and urban party spaces. There is significant overlap between gender norms and biases and stigma around substance use that impacts women in specific ways, including access to care. Researchers describe ways in which fear of violence often keeps women away from care. In addition, men often dominate treatment spaces in less explicit ways, impacting women’s participation in treatment when they do seek care. In intimate partner settings, gendered roles may result in a dynamic in which women are expected to be the nurturer to their male partners who very frequently also are using substances. Finally, in party spaces, women make considerations - including clothes, behavior, and type and amount of substance consumed - to maintain safety. 

Research and Science 

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JAMA Network Open

Medications for opioid use disorder (MOUD), namely methadone, buprenorphine, or naltrexone, remain the most effective treatment for opioid use disorder (OUD), yet they remain underutilized. This cross-sectional study aimed to describe MOUD availability at psychiatric hospitals throughout the US. Researchers found that less than one-half of psychiatric hospital survey respondents provide MOUD. It is additionally concerning that 30% of psychiatric facilities offering medically managed withdrawal did not provide MOUD given the possible harm of this approach including increased risk of overdose. Consistent with prior research in community outpatient mental health facilities, the findings suggest that low MOUD availability is a systemic issue in psychiatric care. This is due to stigma against MOUD, lack of knowledge of the effectiveness of MOUD, and regulations surrounding its provision.

Journal of Safety Research

Alcohol-impaired driving deaths per year remained at about 10,000 from 2010 to 2020 but increased to 13,500 in 2022. This paper analyzed data from the National Survey on Drug Use and Health to study driving under the influence of alcohol (DUIA), marijuana (DUIM), and other drugs (DUID). The prevalence of DUIA was 8.3%, DUIM 5.3%, and DUID 0.9%. All three were most prevalent in the age group 21-25 years, and among males. DUIA was higher for those with a college degree, higher income, and full-time employment. DUIM and DUID were higher among those without a college degree, with lower income, and with no or part-time employment. Between 2016 and 2019, DUIA slightly decreased, DUIM increased (4.5% to 5.3%), and DUID was unchanged. The authors call for improved roadside detection for drugs and standardized toxicology protocols.

Journal of Addiction Medicine

The National Household Survey on Drug Use and Health asks respondents if they consider themselves in recovery from alcohol or drugs. This study examined 3,763 adults who indicated they were in recovery. Past-month alcohol or other drug use (AOD) was reported by 65% of this group, with 51% reporting alcohol use, 33% marijuana use, and <5% use of other drugs. In the nonabstinent group, 55% reported use of a substance for which they had met criteria for SUD in the past year. Females had lower odds of use (aOR=0.7), and lesbian/gay individuals had higher odds of use (aOR=2.4). Mutual aid group attendance was associated with lower odds of use (aOR=0.16). The authors speculate the nonabstinent group may be more likely to be in early recovery and call for research on how abstinence status evolves over time.

Learn More 

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Canadian Medical Association Journal

In this article, the authors provide an update to the Canadian 2018 National Guideline for the Clinical Management of Opioid Use Disorder (OUD). The updated guideline includes 8 recommendations and 2 special considerations but does not consider or make any recommendation regarding injectable medications for OUD treatment. First among the recommendations is the use of methadone or buprenorphine as a first-line treatment, with the recommendation for slow-release oral morphine as a second-line option. The recommendations also support the use of psychosocial treatments as adjuncts (but not making them mandatory) and offering harm reduction strategies in treatment. Opioid withdrawal management alone should not be offered for OUD treatment, but in patients who pursue it, a slow-taper approach should be considered. 

JAMA Network

Opioid use disorder (OUD) is common and associated with inadequate treatment and deaths due to opioid overdose. Harm reduction provides individuals using drugs with resources to prevent substance use-related harms, including overdose, and aims to empower them to live healthier, self-directed lives. Effective harm reduction communication incorporates motivational interviewing, defined as a “collaborative conversation style for strengthening a person’s own motivation and commitment to change.” When delivered in health care settings, motivational interviewing reduces substance use. This article provides a communication framework for clinicians to offer harm reduction care to patients with OUD, including those taking medications for OUD, applying the Relationship: Establishment, Development and Engagement (REDE) model.

JAMA Network

According to the US Centers for Disease Control and Prevention (CDC), an estimated 107,543 deaths due to unintentional drug overdose occurred in the US in 2023. People who use drugs are also at increased risk of infection (e.g., HIV; hepatitis A, B, and C; bacterial skin infections; endocarditis). To decrease the morbidity and mortality associated with drug use, this article outlines harm reduction strategies clinicians can discuss to optimize safety when people who use drugs are not prepared to abstain from use. These strategies include safer supply; overdose prevention; medications to decrease risk of HIV infection; methods to decrease risk of hepatitis A, B, and C infections; and for patients who inject drugs, safer injection and injection alternatives.

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US Centers for Disease Control and Prevention 

The 35th Surgeon General’s Report on Smoking and Health was recently released. Cigarette smoking has decreased from 42% in 1965 to 12% in 2021; however, smoking still causes 1 in 5 deaths in the United States - a total of 490,000 deaths. Secondhand smoke disproportionately affects Black individuals, youth, and those from lower socioeconomic backgrounds. Menthol cigarettes increase the likelihood of tobacco initiation and addiction. The tobacco industry has targeted marketing to specific groups, such as Black and Hispanic communities, and those of lower income. The report calls for media campaigns and improved access to cessation support.

In The News 

National Institute on Drug Abuse (NIDA)

National Institute on Drug Abuse (NIDA)

K-12 Dive

The Regulatory Review

National Public Radio

University of South Florida

Searchlight New Mexico