Southern California PSYCHIATRIST October 2024

GLP-1 Agonist Medications and the Treatment of Substance Use Disorders

by Steven Allen, MD

Addiction is a complex, chronic, and relapsing disease that remains a leading cause of morbidity and mortality. According to the NSDUH, more than 48 million Americans have struggled with a substance use disorder, involving alcohol or illicit drugs, over the last year. [1] Similarly, over 177 million Americans have used a tobacco/nicotine product over the last year. [1] The annual financial cost of substance use remains high. The US Department of Health and Human Services estimates the annual economic impact of alcohol and illicit drug use in the United States at $249 billion and $193 billion respectively. [2] In 2018, tobacco/nicotine use cost the United States more than $600 billion. [3] Despite increasing use associated with tremendous financial and health consequences, available pharmacological treatments remain limited in number and efficacy. Currently, the FDA has only approved pharmacological treatments for opioid, alcohol, and tobacco use disorders. Given the paucity of highly effective and widely accessible medication treatments for substance use disorders, it is imperative to urgently explore other possible novel treatments.  In this context, the gut brain axis, including the gut brain peptide glucagon-like peptide-1 (GLP-1), has garnered increasing attention.

GLP-1 is an anorexigenic incretin hormone released peripherally by the endocrine cells of the small intestine and centrally in the nucleus tractus solitarius (NTS). Functionally, GLP-1 plays a central role in glucose homeostasis, gastrointestinal motility, and the release of insulin and glucagon.  Additionally, GLP-1 medications have been linked to increased satiety, weight loss, improved cardiovascular function, and lower all-cause mortality. Currently, GLP-1 agonist medications carry FDA indications for the management of type two diabetes, weight loss, and cardiovascular disease.

The first study evaluating the association between substance use and GLP-1 agonist medications was published in 2012. [4-6]  Since, a growing body of evidence has surfaced surrounding potential mechanisms of action and clinical efficacy for substance use.  Mechanistically, animal studies have established a clear link between GLP-1 and dopamine release in mesolimbic reward pathway, which is commonly identified as a classical neuro-mechanism of addiction. [5-10]  Interestingly, recent animal studies have also suggested an association between GLP-1 and other potential mechanisms related to addiction, including excitatory and inhibitory neurotransmitters (Glutamate and GABA), the arachidonic pathway, and pathways involving increased neuroprotective and anti-inflammatory effects. [7; 10-13]

From a clinical perspective, rodent and non-human primate studies have tied GLP-1 medications to a reduction in substance induced reward, attenuated cravings and motivation to use, and significant decreases in self-administration of nicotine, alcohol, and illicit substances. [5-10; 14] Similarly, pre-clinical studies have found notable reductions in experienced withdrawal symptoms (including, anxiety, depression, and hyperphagia), increased latency to relapse, and an ability to diminish the risk of relapse whether it be cue-induced, substance-induced, or stress-induced. [5-10; 14] Other animal model studies have shown a reduction in observed hyperlocomotion associated with alcohol, cocaine, and nicotine use, while accelerating extinction of use for all three substances. In fact, several publications have suggested that GLP-1 agonist medications may facilitate the extinction of nicotine use via aversive mechanisms. [9; 14] Additional salient findings include a reduction of alcohol and cocaine seeking behaviors, a reduction in binge alcohol consumption, latency to the first bout of alcohol consumption, a diminished preference for alcohol over water, attenuation of increased alcohol consumption often seen after periods of abstinence/withdrawal, and maintenance of sobriety from alcohol after discontinuation of pharmacological GLP-1 treatment. [5; 8-10]

Thus far, pre-clinical trials have consistently shown promising results in the treatment of substance use disorders, but human studies remain limited.  Preliminary human pilot studies, case reports, retrospective reviews of aggregate electronic health records, and analyses of social media platforms, have highlighted reductions in alcohol consumption, cravings for alcohol, symptoms associated with alcohol use disorder (via AUDIT screening), and the risk for development of an alcohol use disorder or recurrent alcohol consumption in those with a prior diagnosis of alcohol use disorder. [15-17]  Correspondingly, a recent analysis of social media posts, found that roughly 25 percent of nicotine related comments indicated cessation of nicotine use after initiation of GLP-1 medications.[15] A separate electronic health record review found GLP-1 medications to be superior to other anti-diabetic or anti-obesity medications in reduction of cannabis use in patients with comorbid type 2 diabetes and/or obesity. [18]  Human laboratory studies have also shown corresponding reductions in serum GLP-1 concentrations after cannabis and cocaine exposure. [19; 25]  Congruent with preclinical findings, the results from small preliminary human studies are largely promising.

Despite these encouraging results, the need for perspective randomized controlled trials (RCT) to better inform the potential application of GLP-1 agonist medications for substance use disorders persists.  To date, only five randomized controlled trials investigating the use of GLP-1 medications in substance use have been published and the results up to now have remained mixed. ²⁰ The basic study designs and subsequent results of these five published RCTs are summarized below.

Two published, double blinded, placebo controlled, randomized clinical trials have evaluated the efficacy of GLP-1 medications in the treatment of alcohol use disorder. The first RCT trial, conducted by Klausen and colleagues, consisted of 127 Danish participants with alcohol use disorder who received treatment with either the GLP-1 receptor agonist Exenatide and behavioral therapy or saline placebo and behavioral therapy. [21] The study found that Exenatide did not separate from placebo in terms of reducing heavy drinking days at 26 weeks.  However, a subgroup secondary analysis of study participants with obesity (BMI>30kg/m²), in the Exenatide treatment arm, revealed a reduction of heavy drinking days by 23.6 percentage points and a reduction in alcohol consumption by roughly 86 US standard drinks (1205 grams) over a thirty-day period.  Of note, subgroup analysis of participants who received Exenatide, with a BMI<25kg/m², experienced an increase in the number of heavy drinking days by 27.5 percentage points, although total alcohol consumed did not differ between the two groups.

The second published RCT involving alcohol use disorder, conducted by Wium and colleagues, used the Danish National Prescription Registry to compare a cohort of 38,454 new GLP-1 receptor agonist users to 49,222 new users of DPP-4 inhibitors (the enzyme responsible for the breakdown of GLP-1). [22]  In this study participant weight was not reported and primary endpoints consisted of the following alcohol related events: hospital contacts with a primary diagnosis of alcohol use disorder, registered treatment for alcohol in the National Registry of Alcohol Treatment, or purchase of chlordiazepoxide or other medication(s) used for the treatment of alcohol dependence and found in the Danish National Prescription Registry.  The results found those receiving a GLP-1 agonist had a lower incidence of alcohol related events, when compared to DPP-4 inhibitors at 3 months.

Yammine and colleagues conducted a double blinded, placebo controlled, randomized clinical trial evaluating 84 pre-diabetic or overweight participants who were randomly divided into one of two treatment groups: GLP-1 receptor agonist + 21 mg nicotine patch + smoking cessation counseling or placebo + 21 mg nicotine patch + smoking cessation counseling. [23] Primary endpoints included abstinence at 6 weeks (measured by self-report and exhaled CO), withdrawal symptoms, and cravings. Secondary endpoints included post-cessation weight gain and smoking reduction (cigarettes/day).  GLP-1 receptor agonist medications were found to have greater rates of abstinence at 6 weeks, lower tobacco cravings, and lower post-cessation weight gain.

A different double blinded, placebo controlled, RCT, conducted by Lengsfeld and colleagues, looked at 244 cigarette smokers, with no metabolic or weight criteria, who were randomly assigned to one of two treatment arms: GLP-1 agonist + Varenicline 2mg daily + behavioral counseling or placebo + Varenicline 2mg daily + behavioral counseling. [24] At 12 weeks, GLP-agonist treatment was found to have no significant differences to the placebo group in terms of tobacco abstinence and cravings.  However, it was noted that the GLP-1 agonist treatment group experienced less post-cessation weight gain and lower Hemoglobin A1C levels.  These findings are particularly encouraging as post-cessation weight gain may serve as a barrier to abstinence or a trigger for relapse.

Lastly, Angarita and colleagues published a double blinded, placebo controlled, RCT evaluating the effects of GLP-1 agonist treatment on cocaine administration. [25] In this study, treatment with low dose GLP-1 agonist medications did not significantly alter cocaine administration, experienced euphoria, or cravings/desire to use cocaine.  However, it has been suggested that higher dosages of GLP-1 agonist medications may have produced more favorable clinical outcomes.

In summary, the global burden of tobacco, alcohol, and substance use disorders continues to rise, while effective and widely accessible treatment options remain limited.  Up to this point, results from pre-clinical and preliminary human studies, evaluating the potential tolerability and efficacy of GLP-1 agonist medications in the treatment of substance use, are largely promising.  However, there is a dearth of randomized controlled trials with results that are certainly less than conclusive.  From the five published RCTs investigating this topic, only three revealed potential utility for GLP-1 medications in substance use disorders.  Strikingly, in all three positive results, the reduction of substance use was tied to participants with pre-existing metabolic disease. [20]  Presently, there are ten pending clinical trials (examining GLP-1 medications in alcohol, nicotine, and opioid use disorders) but additional RCTs are needed to better elucidate clinical efficacy, safety, and tolerability. [26] More specifically, salient topics requiring further investigation may include evaluation of ideal target patient populations, preferred GLP-1 compounds, preferred dose and duration of treatment, potential variability in pharmacological efficacy between different substance use disorders, medication accessibility and affordability, and a greater understanding of the GLP-1 mechanism of action as it pertains to substance use.  Therefore, given the current scarcity of data, potential risks of GLP-1 medications, and inconclusive RCT results, it presently remains premature to prescribe GLP-1 medications as off label treatment for substance use disorders.  However, the predominant consensus of positive pre-clinical and preliminary human trial results, has created excitement in the field of addiction medicine and certainly warrants further exploration via additional randomized controlled trials.

References:
1. “2023 NSDUH Detailed Tables | CBHSQ Data.” www.samsha.gov, July 2024
www.samhsa.gov/data/report/2023-nsduh-detailed-tables. Accessed 7 Sept. 2024.
Office of the Surgeon General, Assistant Secretary for Health (ASH). “Addiction and Substance Misuse
2. Reports and Publications.” HHS.gov, 29 Mar. 2019,
www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/index.html.
3. CDC. “Economic Trends in Tobacco.” Smoking and Tobacco Use, 2024,
https://www.cdc.gov/tobacco/php/data-statistics/economic-trends/ Accessed 27 Sept. 2024.

4. Egecioglu, E., Steensland, P., Fredriksson, I., Feltmann, K., Engel, J. A., & Jerlhag, E. (2013). The glucagon-like peptide 1 analogue Exendin-4 attenuates alcohol mediated behaviors in rodents. Psychoneuroendocrinology, 38(8), 1259–1270. https://doi.org/10.1016/j.psyneuen.2012.11.009
5. Jerlhag E. (2023). The therapeutic potential of glucagon-like peptide-1 for persons with addictions based on findings from preclinical and clinical studies. Frontiers in pharmacology, 14, 1063033. https://doi.org/10.3389/fphar.2023.1063033
6. Engel, J. A., & Jerlhag, E. (2014). Role of appetite-regulating peptides in the pathophysiology of addiction: implications for pharmacotherapy. CNS drugs, 28(10), 875–886. https://doi.org/10.1007/s40263-014-0178-y
7. Bruns Vi, N., Tressler, E. H., Vendruscolo, L. F., Leggio, L., & Farokhnia, M. (2024). IUPHAR review – Glucagon-like peptide-1 (GLP-1) and substance use disorders: An emerging pharmacotherapeutic target. Pharmacological research, 207, 107312. https://doi.org/10.1016/j.phrs.2024.107312
8. Shevchouk, O. T., Tufvesson-Alm, M., & Jerlhag, E. (2021). An Overview of Appetite-Regulatory Peptides in Addiction Processes; From Bench to Bed Side. Frontiers in neuroscience, 15, 774050. https://doi.org/10.3389/fnins.2021.774050
9. Jerlhag E. (2019). Gut-brain axis and addictive disorders: A review with focus on alcohol and drugs of abuse. Pharmacology & therapeutics, 196, 1–14. https://doi.org/10.1016/j.pharmthera.2018.11.005
10. Klausen, M. K., Thomsen, M., Wortwein, G., & Fink-Jensen, A. (2022). The role of glucagon-like peptide 1 (GLP-1) in addictive disorders. British journal of pharmacology, 179(4), 625–641. https://doi.org/10.1111/bph.15677
11. Zhu, C., Li, H., Kong, X., Wang, Y., Sun, T., & Wang, F. (2022). Possible Mechanisms Underlying the Effects of Glucagon-Like Peptide-1 Receptor Agonist on Cocaine Use Disorder. Frontiers in pharmacology, 13, 819470. https://doi.org/10.3389/fphar.2022.819470
12. “Glucagon-like Peptide 1 Receptor as a Novel Target for Drug Addiction: Preclinical Insights.” by India A. Reddy. Vanderbilt Reviews Neuroscience, 2014, https://cdn.vanderbilt.edu/vu-web/medschool-wpcontent/sites/3/2019/03/25015537/VRN_1.7.15-1.pdf#page=98. Accessed 2 Sept. 2024.
13. Chuong, V., Farokhnia, M., Khom, S., Pince, C. L., Elvig, S. K., Vlkolinsky, R., Marchette, R. C., Koob, G. F., Roberto, M., Vendruscolo, L. F., & Leggio, L. (2023). The glucagon-like peptide-1 (GLP-1) analogue semaglutide reduces alcohol drinking and modulates central GABA neurotransmission. JCI insight, 8(12), e170671. https://doi.org/10.1172/jci.insight.170671
14. Volkow, N. D., & Xu, R. (2024). GLP-1R agonist medications for addiction treatment. Addiction (Abingdon, England), 10.1111/add.16626. Advance online publication. https://doi.org/10.1111/add.16626
15. Arillotta, D., Floresta, G., Papanti Pelletier, G. D., Guirguis, A., Corkery, J. M., Martinotti, G., & Schifano, F. (2024). Exploring the Potential Impact of GLP-1 Receptor Agonists on Substance Use, Compulsive Behavior, and Libido: Insights from Social Media Using a Mixed-Methods Approach. Brain sciences, 14(6), 617. https://doi.org/10.3390/brainsci14060617
16. Quddos, F., Hubshman, Z., Tegge, A., Sane, D., Marti, E., Kablinger, A. S., Gatchalian, K. M., Kelly, A. L., DiFeliceantonio, A. G., & Bickel, W. K. (2023). Semaglutide and Tirzepatide reduce alcohol consumption in individuals with obesity. Scientific reports, 13(1), 20998. https://doi.org/10.1038/s41598-023-48267-2
17. Richards, J. R., Dorand, M. F., Royal, K., Mnajjed, L., Paszkowiak, M., & Simmons, W. K. (2023). Significant Decrease in Alcohol Use Disorder Symptoms Secondary to Semaglutide Therapy for Weight Loss: A Case Series. The Journal of clinical psychiatry, 85(1), 23m15068. https://doi.org/10.4088/JCP.23m15068
18. Wang, W., Volkow, N. D., Berger, N. A., Davis, P. B., Kaelber, D. C., & Xu, R. (2024). Association of semaglutide with reduced incidence and relapse of cannabis use disorder in real-world populations: a retrospective cohort study. Molecular psychiatry, 29(8), 2587–2598. https://doi.org/10.1038/s41380-024-02498-5
19. Farokhnia, M., McDiarmid, G. R., Newmeyer, M. N., Munjal, V., Abulseoud, O. A., Huestis, M. A., & Leggio, L. (2020). Effects of oral, smoked, and vaporized cannabis on endocrine pathways related to appetite and metabolism: a randomized, double-blind, placebo-controlled, human laboratory study. Translational psychiatry, 10(1), 71. https://doi.org/10.1038/s41398-020-0756-3
20. Shen, M. R., Owusu-Boaitey, K., Holsen, L. M., & Suzuki, J. (2024). The Efficacy of GLP-1 Agonists in Treating Substance Use Disorder in Patients: A Scoping Review. Journal of addiction medicine, 10.1097/ADM.0000000000001347. Advance online publication. https://doi.org/10.1097/ADM.0000000000001347
21. Klausen, M. K., Jensen, M. E., Møller, M., Le Dous, N., Jensen, A. Ø., Zeeman, V. A., Johannsen, C. F., Lee, A., Thomsen, G. K., Macoveanu, J., Fisher, P. M., Gillum, M. P., Jørgensen, N. R., Bergmann, M. L., Enghusen Poulsen, H., Becker, U., Holst, J. J., Benveniste, H., Volkow, N. D., Vollstädt-Klein, S., … Fink-Jensen, A. (2022). Exenatide once weekly for alcohol use disorder investigated in a randomized, placebo-controlled clinical trial. JCI insight, 7(19), e159863. https://doi.org/10.1172/jci.insight.159863
22. Wium-Andersen, I. K., Wium-Andersen, M. K., Fink-Jensen, A., Rungby, J., Jørgensen, M. B., & Osler, M. (2022). Use of GLP-1 receptor agonists and subsequent risk of alcohol-related events. A nationwide register-based cohort and self-controlled case series study. Basic & clinical pharmacology & toxicology, 131(5), 372–379. https://doi.org/10.1111/bcpt.13776
23. Yammine, L., Green, C. E., Kosten, T. R., de Dios, C., Suchting, R., Lane, S. D., Verrico, C. D., & Schmitz, J. M. (2021). Exenatide Adjunct to Nicotine Patch Facilitates Smoking Cessation and May Reduce Post-Cessation Weight Gain: A Pilot Randomized Controlled Trial. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 23(10), 1682–1690. https://doi.org/10.1093/ntr/ntab066
24. Lengsfeld, S., Burkard, T., Meienberg, A., Jeanloz, N., Vukajlovic, T., Bologna, K., Steinmetz, M., Bathelt, C., Sailer, C. O., Vogt, D. R., Hemkens, L. G., Speich, B., Urwyler, S. A., Kühne, J., Baur, F., Lutz, L. N., Erlanger, T. E., Christ-Crain, M., & Winzeler, B. (2023). Effect of dulaglutide in promoting abstinence during smoking cessation: a single-centre, randomized, double-blind, placebo-controlled, parallel group trial. EClinicalMedicine, 57, 101865. https://doi.org/10.1016/j.eclinm.2023.101865
25. Angarita, G. A., Matuskey, D., Pittman, B., Costeines, J. L., Potenza, M. N., Jastreboff, A. M., Schmidt, H. D., & Malison, R. T. (2021). Testing the effects of the GLP-1 receptor agonist exenatide on cocaine self-administration and subjective responses in humans with cocaine use disorder. Drug and alcohol dependence, 221, 108614. https://doi.org/10.1016/j.drugalcdep.2021.108614
26. (2024). ClinicalTrials.gov; National Library of Medicine. https://clinicaltrials.gov/search?cond=Substance%20Use%20Disorders&intr=GLP1&page=1&viewType=Card

Existential Musings on a Possibly Post-Pandemic Experience

by Alex Lin, MD

I have recently seen a few graduate students for intake and was struck by how their undergraduate experience was deeply affected by the pandemic.  I reminded me that, in the isolation and quiet of the early part of the lockdown, I had wondered if our vaguely decadent society would ultimately change, and I wished for some sort of shared sense of humility, compromise, and kindness to emerge from the madness and chaos.

I had not realized it at the time, but what I had been hoping for was “post-traumatic growth.”  First coined by Tedeschi and Calhoun in 1995,[1] the term refers to “the process of development of positive changes in the struggle with trauma, and the outcomes themselves.”[2]  Posttraumatic growth is distinguished from “resilience” because the former results in “transformative growth,… [and development] beyond previous levels of adaptation, psychological functioning, or life awareness. It has a quality of transformation or a qualitative change in functioning.”[3]

Posttraumatic growth consists of five domains:  new possibilities, relating to others, personal strength, spiritual change, appreciation of life.[4] The change is not a direct result from the highly-challenging life event but instead comes from

the individual’s struggle with the new reality in the aftermath of trauma… [which] is crucial in determining the extent to which posttraumatic growth occurs…. Psychological crisis can be defined in relation to the extent to which the fundamental components of the assumptive world are challenged, including assumptions about the benevolence, predictability, and controllability of the world; one’s safety is challenged, and one’s identity and future are challenged…. The “seismic” set of circumstances severely challenges, contradicts, or may even nullify the way the individual understands why things happen, in terms of proximate causes and reasons, and in terms of more abstract notions involving the general purpose and meaning of the person’s existence. Such threats to the assumptive world are accompanied by significant levels of psychological distress.[3]

Posttraumatic growth can be influenced by multiple factors:  personality characteristics, management of distressing emotions, support and disclosure, and, perhaps most importantly, the level of cognitive engagement with the crisis.  Cognitive processing results in more robust internal psychic structures.[3]

While there is an overall relationship between PTSD symptoms and posttraumatic growth, the exact association is unclear.  A meta-analysis from 2013 found an overall curvilinear relationship “such that increases in PTSD symptoms are initially associated with an increase in PTG [posttraumatic growth] but that this relationship becomes negative when a critical point is reached in the severity of symptoms experienced.” [5]  However, the authors noted that “none” of the relationships “were particularly strong” (even if they were statistically significant), that trauma type and age had a significant impact on the relationship, and cautioned about translating their study into practical or clinical work.[5]

They also commented on “weak or non-existent relationships between PTSD symptoms and growth when the trauma was the serious ill-health of self or others and those who assist survivors of trauma such as health professionals.”[5]

Ultimately, growth occurs through constructive reflection, the development of narrative, wisdom, and, perhaps surprisingly, some lasting distress from the trauma⁴ (which may help to enhance and maintain growth).[3]

“Posttraumatic” implies that the crisis has abated.  It is actually not at all clear that the pandemic is over.  An article in a Boston University on-line newsletter from earlier this year asked three faculty members (an infectious disease specialist, an epidemiologist, and a virologist) for their opinions; the three experts had rather differing views.[6]

The infectious-disease specialist declined to state if the pandemic was over but did state that society was not experiencing widespread disruption, that she was not seeing large numbers of people with severe disease or needing to be hospitalized, that an endemic could still kill a large number of people (as is the case with malaria), and that it was important to remain vigilant.[6]

The epidemiologist said that answering the question would depend on how widespread the issue was and whether the number of infections were higher than expected.  She noted that infections were still widespread and that the World Health organization had ended the public-health emergency but was still labeling COVID-19 a pandemic specifically to discourage people from normalizing the situation.  She asked rather pointedly:  “The real question… is not whether COVID is still a pandemic, but how much COVID illness and death are we willing to accept?”[6]

The virologist said that the lack of novelty, the lack of unexpected pressure on the healthcare system, and the virus’s continued presence all mean that COVID had become endemic and that one should simply handle COVID as they would any respiratory infection (including being “extra careful” if one were planning to “be around strongly immunocompromised people”).[6]

These experts’ opinions are rather interesting because the “classic” definition of a pandemic “includes nothing about population immunity, virology or disease severity.”[7]

Gallup has been tracking Americans’ opinions about the pandemic being over since June 2021 and provided an up#_edn3date in March 2024 (https://news.gallup.com/poll/612230/four-years-say-covid-pandemic.aspx).  While the headline was that 59% of Americans believe the pandemic to be over, stratifying the data by political-party identification shows rather significant divisions.[8]  The percentage of people responding that life has not returned to normal and will never return to normal has remained fairly consistent since 2021 (43% as of the 03/2024 update), while the number of people stating that life has not returned to normal but will return to normal has dropped significantly (from 46% to 14%).[8]  This perhaps denotes a loss of optimism in the future.

Rather than looking at aggregate data, I thought it might be useful to read narratives on post pandemic experiences.  The Washington Post published such a series last summer, and the article titles were quite varied: [9],[10],[11],[12],[13],[14]

• COVID flipped the introvert-extrovert script. And I hate it.
• How I overcame my fear of touching and learned to love the hug again
• Long covid has derailed my life. Make no mistake: It could yours, too.
• The best thing to do when covid relented? Dance, dance the night away.
• I was immersed in hookup culture — until covid forced me into intimacy
• Covid gave me 2 options: Give in to alcohol addiction, or choose life

When there are so many narratives covering such a wide diversity of experiences, how do we choose on which ones to focus?  The pandemic has caused many of us to question the validity of news outlets and of previously well-regarded government organizations (such as the US Centers for Disease Control and Prevention). The process by which we decide how narratives become dominant have significant implications for information literacy.

One academic librarian has encouraged maintaining “critical thought and healthy skepticism about information on complex issues…, while also cautioning… against sliding into extreme distrust of all expertise.” [15]  She believes that it is “important to look honestly at [the] often legitimate reasons that people’s trust in expertise has declined over the years, rather than simply viewing an increased skepticism in experts as a deficiency of individuals.”[15]

She discusses how claims that the pandemic has ended (or that COVID is becoming more mild) are more “sociological”¹⁵ in origin and how America’s exaltation of “hyperindividualism”¹⁵ (along with capitalism) has led to the normalizing of COVID as “the responsible thing to do: this is how you contribute to a healthy, productive, and pro-growth society and economy.”[15]

These cultural ideals have contributed to the erasure of narratives of those with long COVID.  Indeed, while some of the reader reactions to The Washington Post series were quite humorous (“I did not return as a fine wine or a nuanced bourbon — more an old-fashioned with a bitter twist of lemon.”), [16] others commented on the very real, lasting, and difficult-to-quantify damage caused by COVID:[16]

In some ways, the latter stages of the pandemic felt like a direct attack on people with marginalized bodies….  I will have a hard time forgetting how it felt to be in community with the people our world left behind, left alone, left for dead — on purpose.

and

I went from being a runner, climber, skier and journalist to being disabled, chronically ill and living at home as a 25-year-old. I endured medical gaslighting, and I have dealt with grief and an endless feeling of hopelessness because there is still no cure and the world is moving on from the virus that completely derailed the future I had planned for myself.

and

What is so frustrating is that no one talks about those of us with rare adverse reactions to the coronavirus vaccines. It’s as if we don’t exist.

One reader had a powerful reminder to others:  “…please resist rolling your eyes. You have no idea what people are going through.  And compassion costs you nothing.”[16]

For me, witnessing our country’s varying reactions to COVID has been deeply painful, and my sadness stems from the pandemic being “a mirror on our society, and the image it reflects [being] deeply unflattering.”[1]

I have not witnessed much, if any, societal posttraumatic growth.  The lack of positive change could be partially attributable to the technology that we used (and still use) to reach each other.  A recent report from Microsoft indicated that users of Office spend 60% of their time using digital-communication software (eg., e-mail) and that 70% of respondents felt that they “don’t have enough uninterrupted focus time during the workday.” [2] Online meetings increased by more than 250% from February 2020 to 2022.[18]  A 2019 Swedish study “found correlations between high communication-technology demands and poor health outcomes,”¹⁸ while a very small study conducted by UC Irvine, MIT, and Microsoft indicated that “subjects’ stress levels rose higher the longer they spent on e-mail.”¹⁸

While technology gave us a much-needed way to connect during the early part of the pandemic lockdown, I believe that it has made us all too accessible and has resulted in quantity over quality, in terms of our interactions.  If there has been a lack of growth, it could be because we do not have enough private time for meaningful reflection.  And, as mentioned previously, it is also possible that the (severely) ill health of others is simply not the type of trauma that results in growth.

I think that digital communication gives the impression of connectedness but can ironically leave us feeling alone, depleted, and immersed in our own anxieties.  It has given us a never-ending stream of news about inflation, two on-going wars, and an upcoming presidential election that is causing many (regardless of political affiliation) to understandably feel incredibly distressed.  Technology provides never-ending reminders of how polarized our world is.

Some of my patients who now work from home have mentioned that they miss the privacy, self-reflection, and transition from work/home that the commute provided.

None of us know for how long our world will continue to be so troubling.  I hope that we can all find the time to actively disconnect from the chaos surrounding us and cultivate an internal sense of peace, quiet, and, ultimately, growth and change.

References

[1] Tedeschi RG, Calhoun LG. Trauma & Transformation: Growing in the Aftermath of Suffering.  Thousand Oaks, CA: SAGE Publications, Inc.; 1995. doi:10.4135/9781483326931

[2] Aulov SS, Triplett KN, Tedeschi RG, Calhoun LG.  Posttraumatic growth. In: Friedman, HS and Markey, CH, editors. Encyclopedia of Mental Health (Third Edition). Academic Press, 2023. Pages 796-800.

[3] Tedeschi RG, Calhoun LG. TARGET ARTICLE: Posttraumatic Growth: Conceptual Foundations and Empirical Evidence, Psychological Inquiry. 2004. 15(1): 1-18.

[4] Liu L, Cheng L, Qu X. From existential anxiety to posttraumatic growth:: The stranded traveler during the pandemic outbreak. Ann Tour Res. 2023 Mar;99:103548. doi: 10.1016/j.annals.2023.103548. Epub 2023 Mar 10. PMID: 36936515; PMCID: PMC10000268.

[5] Shakespeare-Finch J, Lurie-Beck J. A meta-analytic clarification of the relationship between posttraumatic growth and symptoms of posttraumatic distress disorder. J Anxiety Disord. 2014 Mar;28(2):223-9. doi: 10.1016/j.janxdis.2013.10.005. Epub 2013 Nov 2. PMID: 24291397.

[6] Colarossi J. Is COVID-19 still a pandemic? The Brink [Internet]. 2024 March [cited 2024 September 24].  Available from https://www.bu.edu/articles/2024/is-covid-19-still-a-pandemic/.

[7] Kelly H. The classical definition of a pandemic is not elusive. Bull World Health Organ. 2011 Jul 1;89(7):540-1. doi: 10.2471/BLT.11.088815. PMID: 21734771; PMCID: PMC3127276.

[8] Brenan M. After Four Years, 59% in U.S. Say COVID-19 Pandemic Is Over [Internet]. 2024 March 15 [cited 2024 September 23].  Available from https://news.gallup.com/poll/612230/four-years-say-covid-pandemic.aspx.

[9] Makkai R. The pandemic flipped the introvert-extorvert script. And I hate it. The Washington Post [Internet]. 2023 July 12.  Available from https://www.washingtonpost.com/opinions/2023/07/12/rebecca-makkai-post-pandemic-covid-introvert-extrovert/.

[10] Ross G. How I overcame my fear of touching and learned to love the hug again. The Washington Post [Internet]. 2023 August 30.  Available from
https://www.washingtonpost.com/opinions/2023/08/30/ross-gay-covid-post-pandemic-hug-delight/.

[11] Miller M. Long covid has derailed my life. Make no mistake: It could yours, too. The Washington Post [Internet]. 2023 August 30.  Available from https://www.washingtonpost.com/opinions/2023/08/09/madeline-miller-long-covid-post-pandemic/.

[12] Field A. The best thing to do when covid relented? Dance, dance the night away. The Washington Post [Internet]. 2023 July 19.  Available from https://www.washingtonpost.com/opinions/2023/07/19/andy-field-post-pandemic-covid-dancing/.

[13] Roberson B. I was immersed in hookup culture — until covid [sic] forced me into intimacy. The Washington Post [Internet]. 2023 July 19.  Available from
https://www.washingtonpost.com/opinions/2023/07/26/blythe-roberson-post-pandemic-covid-dating/.

[14] Garbes A. Covid gave me 2 options: Give in to alcohol addiction, or choose life. The Washington Post [Internet]. 2023 Aug 2.  Available from https://www.washingtonpost.com/opinions/2023/08/02/angela-garbes-post-pandemic-covid-alcohol-drugs-sobriety/.

[15] Baer A. Dominant COVID narratives and implications for information literacy educational in the “post-pandemic” United States [Internet].  In the library with a lead pipe. Available from https://www.inthelibrarywiththeleadpipe.org/2023/covid-narratives/.

[16] Balderama J. The pandemic changed us in so many ways. Here are just a few. The Washington Post [Internet]. 2023 October 11.  Available from https://www.washingtonpost.com/opinions/2023/10/11/post-pandemic-covid-readers-react/.

[17] Yong E. Long COVID Is Being Erased—Again. The Atlantic. 2023 [Internet]. 2023 April 15 (revised 2023 April 21). Available from https://www.theatlantic.com/health/archive/2023/04/long-covid-symptoms-invisible-disability-chronic-illness/673773/.

[18] Newport C. An Exhausting Year in (and Out of) the Office. The New Yorker [Internet] 2023 Dec 27. Available from https://www.newyorker.com/culture/2023-in-review/an-exhausting-year-in-and-out-of-the-office.

Prop 32 Affects Residents Too!

by Justin Nguyen, DO

The wages of resident physicians in California are on the ballot this November in the form of Prop 32, which, if passed, would require employers of 26 or more workers to pay their workers a minimum of $18/hour starting January 1, 2025.

This is much less than what residents earn, but they would still be impacted by Prop 32. In California, residents are classified as “exempt” workers who must be paid at least twice the state minimum wage. Currently this amounts to an annual salary of $66,560.

The minimum PGY1 salary in the state would increase to $74,880 if Prop 32 passes, and $68,640 if the measure is defeated (reflecting an increase of the state minimum wage to $16.50/hour in 2025).

For comparison, below are the current PGY1 salaries for psychiatry residency programs in the SCPS region based on information from their websites:

*This figure was obtained from the program website, but unclear if it is up-to-date as it is less than the minimum salary for exempt workers in 2024.

How might Prop 32 affect residents’ standard of living?

Medical school graduates carry an average medical school loan debt of $234,597 while grappling with rising costs of living. The minimum PGY1 salary has risen 14% since 2021. In the same time period, the Fair Market Rent (i.e. the 40th percentile in a given area) for 1-bedroom apartments rose 25-45% among counties in Southern California. An increase in the minimum wage could help to narrow this gap.

One might point to SB 525 (which increased the health care worker minimum wage to $25/hour) and conclude that residents will soon benefit from a wage increase regardless of whether Prop 32 passes. However, under SB 525, the minimum salary for exempt health care workers must be at least 1.5 times the health care minimum wage, which, for those in small facilities with less than 10,000 workers, will progressively increase to $25/hour by July 2028. Until then, SB 525 would not result in a significant salary increase for residents.

What about the cost to hospitals?

If Prop 32 passes, a hospital with 100 residents would spend $624,000 more per year on resident salaries (not including benefits, which often amounts to 30% of salary) than if the measure fails, assuming a current PGY1 salary of $66,560. There is also a cost to hiring faculty to train residents, which varies by program. These costs are offset by CMS payments, which average about $140,000 per resident per year, as well as the revenue and value generated for the hospitals through the direct patient care and documentation carried out by residents.

Recognizing that hospitals throughout the country are struggling financially, critics of resident wage increases might forecast statewide hospital closures (or at least vicious budget cuts and layoffs) if Prop 32 passes. Does this sufficiently justify the current state of resident compensation, or does it speak instead to a need for hospital executives to pivot their approach to their budgetary decisions? Either way, we can’t ignore the reality that California’s minimum wage laws impact the strength of the healthcare workforce.

SCPS DMURR Position

Position Title: Deputy Minority and Underrepresented Groups Representative (DMURR)

Tenure: 2 year total commitment. June 2025 – May 2026 as DMURR. The DMURR is
then expected to serve as the Minority and Underrepresented Groups Representative
(MURR) and head of the Diversity and Culture Committee in the following year June
2026 – May 2027.

Duties:

• Attend monthly Diversity and Culture (D&C) Committee meetings. These meetings are
  typically on the last Monday of each month from 7pm – 8pm (approx. 10 meetings per
  year). The DMURR is a voting member on the D&C committee.
•  ○ Keep minutes for monthly D&C Committee meetings and provide them to the
  MURR and SCPS Executive Director in a timely fashion.
• Attend half of the monthly Government Affairs Committee (GAC) meetings in conjunction
  with the MURR (approx. 5 of 11 meetings per year) unless otherwise designated to
  another D&C committee member. These meetings are typically on the second Tuesday
  of each month from 7pm – 9pm. The DMURR is a voting member on the GAC
  committee.
• Attend monthly SCPS Council Meetings (approx. 10 meetings per year) and be prepared
  to share updates on the D&C committee upcoming projects or events. These meetings
  are typically on the second Thursday of each month from 7pm – 9pm. The DMURR is a
  voting member on the SCPS Council.
• Contribute a minimum of 1 article per year to the SCPS newsletter for the February
  Black History Month special edition.
  Contribute to planning and executing the annual SCPS Black History Month event in
  February in conjunction with the MURR.

Application opens: September 24, 2024

Application closes: October 25, 2024

Application Requirements and Process:

• Applicants must be an SCPS District Branch member and be willing to serve as
  MURR in the year following their DMURR tenure
• Candidates are encouraged to express their interest in the position to SCPS.
  These will be reviewed by the D&C and Nomination committee and Council.
• Applicants must provide a brief candidate statement (<200 words) and brief CV
  (<200 words). The candidate statement will be published in the February 2025 SCPS newsletter
• SCPS members will vote by ballot on DMURR candidates in March 2025

June Council Highlights

INTRODUCTIONS  and ORIENTATION                              Dr. Rees

Council members introduced themselves to each other. Orientation materials present in the meeting Dropbox were reviewed, including elements from legal orientation by attorney Dan Willick, council member duties/expectations, basics of parliamentary procedure, how to find SCPS bylaws on SCPS website

PRESIDENT’S REPORT                                                          Dr. Rees

1. Training Advocacy Outreach – our goal this year is to visit all training programs in SCPS area, not only for recruitment, but to help instill the importance of psychiatric advocacy in trainee psychiatrists.
2. CSAP GAC representatives – 5 representatives, 2 voting and 3 nonvoting. Dr. Goldenberg and Dr. Kelly will be voting members. Dr. Rees will attend as a nonvoting member.
3. Leadership Transition meeting report: As part of CSAP and Area 6 Guidelines, the SCPS executive committee will meet with representatives yearly to see about feedback and transition. This meeting occurred June 3, 2024. Highlighted legislative successes in the preceding year. Identified challenges and suggested goals – separate admin meetings, minutes, financial reports, discussion of non-advocacy items, plans for how to continue advocacy for items even if desired legislative outcome is not achieved. Discussion also of contributions by the different District Branches. Discussion of lack of clarity at times in best way to work with APA – plan for APA representation workgroup chaired by Assembly Reps Dr. Red and Dr. Silverman workgroup to improve ability to liaise effectively with APA on issues of concern to Area 6 & CSAP.
4. APA Reception – concern of cost, so have been looking at co-hosting by Professional Risk Management Services (PRMS) as a co-sponsor.  Motion made that SCPS Council authorize the Executive Council to negotiate final details of contract with PRMS over the summer break, to be ratified in September.
5. Judges and Psychiatrists Leadership Initiative (JPLI) – sponsored by APA Foundation, pairs psychiatrists and judges to educate criminal court judges about the basics of mental illness. Ultimate goal is to promote alternatives to incarceration. Two trainings per year. Judge Bianco and Dr. Bindra are doing the first training in August. Email Dr. Bindra if interested in the training.
6. Update on May newsletter submission that was rejected by newsletter editors – author asked to disenroll from SCPS and threatened. Motion at April meeting to ratify editor’s decision not to publish the article Legal counsel SCPS has discretion to accept or reject articles.  Executive Committee voted to refund the membership dues – Council ratified.
7. Moynihan AP Update: Planning to follow-up with Area 6 APA BOT member Dr Weissman about this. There was a panel held by APA Division of Diversity and Health Equity to discuss this, our Diversity and Culture Committee did not attend because this was not our request in our Action Paper and we continue to pursue the APA repudiating the Moynihan Report
8. Unhoused Workgroup: Dr Chang offered a summary of the committee’s work this year. Final presentation to come next meeting.
9. Membership Recruitment: File is complete, plan is for members to present at local training programs to support recruitment.
10. Budget: The budget committee is working on a draft budget. There was discussion about budget for next year with increased costs with APA Meeting in Los Angeles and expectations for membership numbers.  There is a goal to find some free venues for some programming next year. There was some discussion about plans for SCPS contributing to CSAP PAC.
11. Program committee which organizes CME and educational programming. If interested in joining committee, please reach out to Ms Thelen

PRESIDENT ELECT REPORT                                                Dr. Kelly

1. Review of some elements of newsletter, thank you to June authors
2. 2024-2025 Newsletter Submission: Google doc for signup sent with May Council invite – importance of council authorship emphasized; please sign up by June 20^th (otherwise Mindi/Editor will assign the month)
3. Article topics due by 15^th of previous month, article itself due 9am on 1^st of the month
4. Newsletter Tips and Requirements distributed in meeting Dropbox prior to meeting.
5. Newsletter Committee working on a slightly more formal submission form
6. Motion passed to change Newsletter Format to blog style so more easily read on mobile device, distributed by email, links to individual articles.
7. Newsletter Guidelines and Article Submission: Dr Goldenberg shared that it would also be helpful for the committee to review our guidelines which include that articles should be relevant to mental health related topics. There was discussion about a specific article which was not published.

Motion approved: We will reach out to legal counsel now before further decisions will be made

GAC ACTION ITEMS                                                                Drs. Shaner and Wood

GAC Report distributed in advance in the Dropbox. Report from monthly meeting was provided with status of several bills that are legislative priorities for CSAP.

The following action items were discussed with the following motions approved:

1. Motion 1: That SCPS Council direct GAC to craft a request to FDA requesting to conduct a study to assess the risk of stimulants based on real world data, and to determine from what entity (e.g., SCPS, CSAP) the letter should originate. (See GAC report in Dropbox, Attachment 1). – Motion passed.
2. Motion 2: [Motion passed to amend motion to support position as follows]: That SCPS Council take a support if amended position on AB 2154 (Berman). https://leginfo.legislature.ca.gov/facess/billNavClient.xhtml?bill_id=202320240AB2154 — motion passed by unanimous consent
3. Motion 3: [Motion passed to amend motion to oppose unless amended position as follows]: SB1400 (Stern). https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240SB1400 — motion passed by unanimous consent
4. Motion 4: That SCPS endorse the nomination of Dr. Halpin for California Medical Association Council on Science and Public Health and send a letter of support to CMA. (See Dr. Halpin CV in Council Dropbox) – Motion passed.

ASSEMBLY REPORT                                                               Assembly Reps Dr.  Red – & Dr. Silverman

1. More detailed Assembly report distributed in advance in meeting Dropbox
2. The APA Assembly is like the “US House of Congress” for the APA. Representation in Assembly is based on membership. Assembly is an advisory body to APA board of trustees– writes action papers that get debated and voted on after discussion on the Assembly floor.
3. Assembly had election, has new officers (Speaker, Recorder).
4. Former APA CEO Saul Levin retired, and APA has new CEO
5. On website, members can access all the action papers proposed and those approved by the Assembly – one goal of Assembly reps this year is to track what happens to action papers approved by Assembly that later are not acted upon in further APA process.

1. TREASURER’S REPORT                                                         Dr. Wood
2. May Financials and Cash on Hand Report

May Financials were provided in dropbox to Council ahead of the meeting.

1. Budget presented and approved by Council vote.

 VII.         MEMBERSHIP REPORT                                                  Dr. Ijeaku

Motion approved: The new members and membership report was approved.

1. COMMITTEE REPORTS                                                        Chairs

Committee reports were abbreviated to meeting timing

1. Alternatives to Incarceration – Dr. Wood
2. Access to Care – Dr Friedman
3. Diversity and Culture – working on George Mallory award & avenues for action RE: Moynihan report after stall moving action through
4. DFAPA: Motion Approved: Candidates were reviewed and approved.
5. GAC – see above
6. Unhoused Workgroup Dr Chang – trying to identify barriers