Addiction Policy Forum Blog

6 min read

Can CBD be used to treat Angelman syndrome? Here’s what new UNC research says

By Mark Gold, MD on October 17, 2019

Cannabidiol (CBD) is a “phytocannabinoid” part of cannabis, or an element created from the cannabis plant. According to a recent New York Times article, “The CBD industry is flourishing, conservatively projected to hit $16 billion in the United States by 2025. Already, the plant extract is being added to cheeseburgers, toothpicks and breath sprays."1 The FDA has approved Epidiolex, a CBD oral solution, for prescriptions to patients two years of age and older to treat certain intense forms of epilepsy, Lennox-Gastaut syndrome or Dravet syndrome, marking the first official go-ahead for a marijuana-derived substance.2 CBD, in short, makes headlines. Yet some consumers buying a CBD product sold over-the-counter have had difficulty finding a label and knowing what they’re actually getting.3 For other potential consumers, the biggest questions aren’t about a buzzy new wellness trend—they’re about failing a drug test after acquiring impure CBD or THC in a purchase.4 

Consumers try to balance these fears with the purported benefits CBD. It is true that Epidiolex has been life-changing for the seizures associated with Lennox-Gastaut syndrome and Dravet syndrome. For parents and children coping with these conditions, all other treatments have failed. CBD may have benefits for other patients with rare or difficult-to-treat neurological diseases. In a recent study, researchers at the University of North Carolina wondered if CBD might help treat individuals with another condition involving severe seizures, Angelman syndrome. 

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8 min read

Substance use disorders take a toll on more than just health

By Mark Gold, MD on October 10, 2019

Many Americans are aware of the United States’ current overdose and addiction epidemic. For patients, families, friends, and loved ones, the tragic health and behavioral effects of substance use disorders (SUDs) are readily recognizable at a level of intimate, granular detail. Among individuals who have used substances, not all have SUDS, but many have spent money on illicit substances. SUD-related discussions frequently focus on survival or addiction, sometimes looking past another elephant in the room: finance. A recent RAND report for the Office of National Drug Control Policy (ONDCP) sheds an important light on how much money we pay for illegal drugs by highlighting Americans’ expenditures on methamphetamine, marijuana, heroin, and cocaine.

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9 min read

The truth about MAT? Patients know the virtue

By Mark Gold, MD on October 3, 2019

47,600 people died from drug overdoses involving opioids in 2017. Between 2012 and 2018, the number of fentanyl-induced fatal overdoses rose dramatically, accounting for a majority of overdose deaths. While preliminary data from the Centers for Disease Control shows a marginal decline in fatal overdoses in 2018, from 70,237 to 68,557, it also reveals that fentanyl is still the primary cause of fatal overdoses.1 Naloxone is a non-opioid wonder drug that can reverse an opioid overdose. It is short-acting, and by temporarily reversing the effects of opioids, it gives a person with an opioid use disorder (OUD) a second chance—an opportunity to receive treatment. As a result of campaigns by, among others, the Surgeon General2 and the CDC to improve naloxone access, retail pharmacies increased naloxone dispensing from 2012 to 2018. Despite the increase in dispensation by pharmacies, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions in 2018.3 In the old days, I remember patients saying that they felt stigmatized at the pharmacy when they heard, "Mr. Jones, your Elavil is ready." Stigma kept many depressed patients from filling prescriptions. But in this case, is the challenge both stigma and the lack of pharmacist or health care provider education?4 It is tough to pinpoint a cause explaining this data. 

The CDC and Surgeon General encourage us to improve naloxone access at the local level, including through prescribing and pharmacy dispensing. Widespread distribution of naloxone is an essential component of the public health response to the opioid overdose epidemic. Unfortunately, the lowest rates of naloxone dispensing are in the areas with the highest opioid overdose rates. We are in the third phase of the opioid epidemic, with pain clinics’ overprescribing practices overtaken first by heroin and, more recently, by fentanyl. Individuals who overdose often overdose again, and many patients treated in addiction programs or health providers' offices through MAT often relapse.

For the treatment community, adverse outcomes and continued overdose deaths are, naturally, extremely upsetting. OUD treatment program employees frequently complain of burnout. High turnover in many programs is a major problem. Some are frustrated by recidivism rates, others because some patients are not offered MAT. Some patients cease their MAT course, and others drop out of treatment altogether. Yet experts have consistently agreed that while MAT, due to a lack of options, has not helped us combat cocaine or methamphetamine use disorders, it can be enormously helpful in managing OUD. A recent review, written by James Bell and John Strang, looks at the overall evidence on MAT and compares the relative benefits of different medications, helping to shed light on this critical public health issue. It is important to keep in mind, however, how contentiously and frequently some of our evidence is debated. We lack, for example, prospective, long-term, oncology-like, 5-year studies on the subject. MAT is debated—and so are standards measuring patient "outcomes." For a physician with an OUD, the relevant outcome standards may include a return to practice, 5-year sobriety, urine testing, and fitness for duty. In other cases, outcome standards may include coming to a treatment program, or following an MAT course, or simply not overdosing or dying. 

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10 min read

Look on the bright side—new research shows that it helps you live longer

By Mark Gold, MD on September 26, 2019

 

Everyone knows someone who always seems positive, even in challenging situations. To them, the glass is always half full. For example, Microsoft founder Bill Gates is one fabulously successful optimist:1

“In my own life I’ve been extremely lucky. But even subtracting out my personal experience, I think the big picture is that it’s better to be born today than ever, and it will be better to be born 20 years from now than today….So, yes, I am optimistic. It does bother me that most people aren’t.”2

When viewing an image of a glass containing an equal amount of liquid and empty space, 58 percent of Americans felt that the glass was half-full, according to a survey conducted by One Poll on behalf of Borden milk.3 People who view a glass as half-full think more optimistically, decisively, and with more creativity.

It’s common for many individuals to seek out self-help or turn to “positive thinking” after a crisis or particularly stressful point in their lives, and common for others to mock such efforts as misguided or naive. Individuals with depression have problems finding positive aspects of life and may even believe that the proverbial "dark cloud" hovers over their heads. Behavior and motivation-oriented substance use disorder treatment programs often encourage patients to cultivate positive beliefs and to try to focus on positive developments, and some patients approach these practices with skepticism. These programs may advise: fake it till you make it, or shoot for the stars and settle for a moon landing. 

Research, however, consistently demonstrates the benefits of optimism across a number of key health functions. Studies show that optimism can decrease mortality,4 reduce the risk of stroke,5 reduce the risk of heart disease,6 present fewer progressions of carotid disease,7 and improve pulmonary function,8 among other health benefits. So why might an optimistic disposition and positive attitudes lead to better health outcomes, and just how beneficial are these approaches to life?


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7 min read

What is TMS and can it help treat withdrawal, addiction, and patients with SUDs like it can treat depression and OCD?

By Mark Gold, MD on September 19, 2019

In April, The Atlantic published a piece about a young woman who became a viral internet sensation after she was photographed wearing a futuristic-looking hat or device on her head.1 Some online commentators dubbed the large, grey headwear, connected by a strap under the chin, “the depression helmet.” What the commentators did not understand is that such devices are part of a safe, effective, FDA-approved treatment for depression: transcranial magnetic stimulation, or TMS. At the University of Florida, in 2008, I was part of a team that purchased one of the first TMS machines sold after FDA approval. We bought other machines and did TMS research as well. Since that time, the technique has been used successfully to treat depression around the world. It was also approved in 2013 for the treatment of pain associated with certain migraine headaches, and more recently approved for the treatment of Obsessive-Compulsive Disease.2

At least 100 randomized clinical trials have been completed in an attempt to find a MAT which might treat cocaine use disorder, employing over 50 chemical compound medications. With very little progress made from early work3, none have been shown to be particularly useful4, until the current day and TMS. Treatment must reverse more than acute or even chronic dopamine neuron effects of cocaine. The TMS research group at the National Institute of Drug Abuse (NIDA) in Baltimore works on TMS research, dopamine plasticity, cocaine and SUD-related dopamine changes. TMS offers us a chance to intervene against cocaine and other substance’s ability to change the firing rates and key brain circuits that ultimately reduce dopamine release. The TMS research group is working to define how SUDs change the brain, intrinsic and synaptic plasticity control dopamine neurons, and what might be done to return the brain to pre-drug functionality.5

NIDA TMS researchers were featured in a cover story on the science of addiction in National Geographic.6 This article describes how a psychiatrist in Italy, who has treated addiction for 30 years,  became interested in TMS and began using it for treatment. It also details the successful use of traditional TMS treatment on a chronic relapsing patient, treated as if he had a naturally occurring depression. The psychiatrist, patient, and NIDA researchers are all interviewed for the story. TMS is not shock therapy; it delivers electromagnetic pulses to the brain in dopamine rich areas, resulting in painless, rapid magnetic pulses delivered through a pad or cap or hat. It is called non-invasive, and clearly has the ability to use  magnetic stimulation to drive the brain’s circuitry with electric currents. TMS can increase and decrease cortical excitability, through high and low frequency wave generation.  Scientists are very excited about this as TMS may help rebuild neural connections, or possibly regenerate dopamine systems damaged by substance use. The psychiatrist featured in the National Geographic article, Luigi Gallimberti, MD, has subsequently used TMS to treat other addictions. 

Medication assisted therapies are approved and used for detoxification, maintenance, and relapse prevention. Unfortunately, these do not address many of the changes produced by cocaine and other drugs. Even patients following these treatment plans and taking medications often feel a lack of energy, diminished pleasure, and declining enthusiasm, and drop out of treatment. TMS might not help people to stop using drugs, but it could be beneficial in helping with addiction and post-addiction related depression and anhedonia.7 TMS researchers have become part of a promising frontier for combating craving, addiction, relapse, and co-occurring depression. Greeting with laughter images of TMS devices, caps, and hats is a perfectly unhelpful reaction in the middle of a major opioid crisis.

FDA approval for treating depression through TMS piqued interest in applying the technique to substance use disorders, since depression is often a major part of SUDs, and a cause of relapses and overdoses, as a recent consensus review on the current state of non-invasive brain stimulation science pointed out. Neuroscience research has helped establish connections between substance-using behavior and particular neural circuits, which prompted additional interest in using TMS and related techniques to treat substance use disorders. TMS is no longer an experiment. With time, SUD researchers have compiled more studies on non-invasive brain stimulation, symptoms, and outcomes, leading to new reviews on relative effectiveness and future development prospects.


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8 min read

What you should know about the multistate outbreak of severe lung problems linked to e-cigarettes and vaping

By Mark Gold, MD on September 12, 2019

The Centers for Disease Control (CDC) recently issued a warning about vaping following a multistate outbreak of severe lung problems linked to the use of electronic cigarettes.1 According to the CDC, there are, as of September 6, 450 reported cases of possible vaping-linked lung problems across 33 states and 1 territory, resulting in 6 deaths.2 Officials have not identified a specific e-cigarette product as a cause of the illnesses, meaning that various devices on the market could be contributing to this alarming pattern. Patients admitted for lung problems report difficulty breathing, fatigue, fever, nausea, and vomiting. Somehow, to proponents and purveyors of e-cigarettes, the very idea that vaping could be dangerous seems to have come as a surprise.3 

The CDC updated its warning to suggest that e-cigarette and vaping device users refrain from using the products at all during the course of its investigation. It has also warned against buying counterfeit or street vaping products, including those with THC or other cannabinoids, and against modifying e-cigarette products. Moreover, the CDC urges youth, pregnant women, and adults who do not currently use tobacco products to refrain from using e-cigarette products, and encourages individuals who smoke and want to quit to use FDA-approved medications instead of e-cigarettes. Some health officials and experts believe that street vaping products with illicit or tainted substances may be behind the outbreak of lung problems, but no one can be certain at this point. Some patients have reported using vaping cartridges with THC or cannabinoids, but others have reported using different vaping cartridges without such substances. Most contain ingredients not generally tested for chronic inhalation in humans, and, to make matters worse, they can become contaminated in ways detrimental to respiratory and heart health.4 It is unlikely that any substance you inhale has been tested for safety for weeks, months, or over the long haul. But inhalation from vaping has effects on the lungs that are dramatic, can be easily seen on imaging5, and do not seem easy to reverse. Tobacco smoking in the English colonies of North America started early and peaked in the U.S. in the 1960s and 1970s, credible evidence proving its causal links to cancer, emphysema, and bronchitis emerging only over a century after its explosive growth and wild popularity.6 Why would boosters and defenders of today’s e-cigarettes, looking back at this history, believe that research would come to indicate the product’s benefits for the lungs, or for the respiratory health of those they may expose to vaping?

While experts and officials will continue to study this outbreak and may identify particular illicit substances as the culprit, the headlines have naturally raised questions for individuals who vape about long term consequences. What we know about cigarette smoking is bad enough, but there are few surprises. Here, we’re in uncharted territory. Yes, the FDA and other agencies will look at the broader health and safety of e-cigarette products and devices, but in the meantime, users will need to be evaluated and hope that their own lungs are not compromised in ways that only become clearly understood after they stop, or years down the line. While receiving considerably less media coverage, journalists recently found that the FDA began investigating vaping-associated seizures after some users of JUUL, the top-selling vaping product in the U.S., submitted claims of seizures to the administration’s safety portal.7

It is important to note that Research You Can Use previously observed that there is not yet enough evidence to conclude whether e-cigarettes are suitable for smoking cessation. Some researchers now suggest that vaping nicotine may not be safer than smoking tobacco cigarettes.8 More recently, the FDA has agreed that JUUL’s claims of comparative safety are unproven.9 Other new studies have looked at the relative health of ingredients in some e-cigarette products, and the effects of vaping on the vascular system. The truth is that it’s risky and scientifically invalid to start from the premise that drugs are safe until proven dangerous. It reminds me of cocaine being touted as safe, or non-addicting, or even as “the champagne of drugs” until the aftermath of widespread use in the 1970s and 80s demonstrated that it was highly addictive and led to heart problems, brain damage, and other diseases.10

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