News
The ASAM Weekly for July 21, 2026
This Week in the ASAM Weekly
Alcohol is our lead this week, anchored by a compelling new study tracking "Trends in Alcohol-Related Deaths in the United States Over 55 Years." While recent 2020s data offered some encouraging signals regarding use and impact, this long-term analysis reveals that alcohol-related mortality has increased substantially over more than five decades, with specific demographics bearing a disproportionate burden. Expanding on this focus, we also feature a critical piece in Alcohol on the foundational impacts of prenatal alcohol exposure. I was delighted to see this broader national momentum around alcohol-related public health initiatives, particularly a recent feature in STAT+ highlighting the urgent need for scalable screening, targeted public messaging, and enhanced clinician training.
Risk perception is another major theme in this issue, especially given the well-established clinical reality that risk perception is inversely related to substance use. A recent Washington Post perspective ("I smoked cannabis for nearly 20 years. Here's what I wish I knew at 13") beautifully illustrates how early-life perception shapes long-term use trajectories. We see a similar cognitive pattern with tobacco in a new study from JAMA Network Open; individuals often perceive very low nicotine cigarettes (VLNCs) as less harmful. While clinicians have long worried about compensatory smoking with VLNCs, a new systematic review offers encouraging news, finding minimal evidence of compensation, a promising signal as the FDA considers a low-nicotine product standard. Conversely, a more alarming perception gap exists with opioids: another JAMA Network Open recent study found that a majority of middle school students perceived zero risk in trying fentanyl. While that risk perception improves over time, roughly a third of 12th graders still fail to see great risk in experimentation. On the treatment side, public and patient perception of court-mandated care remains a highly debated topic, now expertly summarized in a comprehensive review in Addiction.
Turning to treatment access and efficacy, we feature a study in the Substance Use & Addiction Journal demonstrating the feasibility of shared medical appointments to expand provider capacity. While much of that care model research has focused on opioids, we also received strong affirmation from a JAMA Network Open trial confirming that buprenorphine-naloxone significantly outperforms naltrexone for treatment of OUD after acute opioid withdrawal. Furthermore, with a major shoutout to the ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder, we are excited to share a new study from the Journal of Addiction Medicine adding to the evidence base for using mirtazapine to treat hospitalized patients with stimulant use disorder (StUD). Pair these clinical advancements with recent LA Times headlines tracking the broader rollout of contingency management, and there is genuine reason for optimism.
Ultimately, while our field is seeing highly encouraging signals, from innovative access models to robust, evidence-based treatments, the 55-year alcohol mortality data serve as a stark reminder that our systemic public health interventions still have a long way to go.
Smita Das, MD, PhD, MPH
Editor in Chief
with Co-Editors: Brandon Aden, MD, MPH, FASAM; John A. Fromson, MD; Sarah Messmer, MD, FASAM; Jack Woodside, MD
and Contributing Editor: Jessica Gregg, MD, PhD, FASAM
This study of alcohol-related mortality trends since 1968 used primarily death certificate data from the CDC WONDER database. Between 1998 and 2023 there were 1.3 million alcohol-related deaths. Overall age-adjusted mortality rates (AAMR) per 100,000 increased from 13 to 19. Rates increased from 1968 to 1980, declined from 1980 to 2000, and began an accelerating increase from 2000 to 2023, with a peak during COVID. AAMRs were higher for males (increasing from 20 to 28) than for females (increasing from 7 to 11). AAMR declined by 50% for Black individuals (from 28 to 14) and nearly doubled for Whites (increasing from 11 to 21) resulting in a dramatic racial inversion. Among age groups, the highest mortality was for 65+, attributed to baby boomer heavy drinking plus frailty of age. The largest increases were seen in the Midwest with the Northeast remaining stable.
Prenatal alcohol exposure (PAE) disrupts fetal development and contributes to fetal alcohol spectrum disorders. PAE alters choline metabolism, which is critical for brain development. Although choline supplementation improves hippocampal-dependent behaviors, its mechanisms of action remain unclear. Using a rat model, researchers found that PAE did not produce lasting changes in overall choline levels but did induce sex-specific alterations. These include reduced betaine and betaine:choline ratios in females and differential effects on metabolic markers related to oxidative stress and methylation. Choline supplementation modulated these pathways in a sex-dependent manner, suggesting distinct metabolic mechanisms by which it may mitigate neurocognitive deficits associated with PAE.
Mandated substance use disorder (SUD) treatment has significant public support, yet in addition to questions about health outcomes, there are also ethical considerations. Researchers conducted a systematic review of qualitative research to evaluate the perceptions and experiences of participants and identified 5 considerations: question of choice to participate, choice of treatment services, potential conflicts of interest of providers, involvement of courts in treatment decisions, and targeting people who may not need treatment. While participants often reported positive perceptions about their treatment, some—including some who didn't believe they had an SUD—also expressed they felt they didn't have a choice. The authors note that given variability in perceptions, there is a need for variability in policies and programs.
Shared medical appointments (SMA) is a group-based clinical care model with individual medical management that has been used for chronic disease management. Researchers conducted a systematic review of SMA use for substance use disorder (SUD) treatment. The review included 14 studies with SMAs implemented in a range of settings with variations in structure but typically co-led by a physician and therapist with other various team members. In general, the SMAs had good treatment retention and treatment participation, while evidence around SUD and mental health outcomes were variable. The researchers noted that SMAs are feasible and are a useful team-based approach, but more studies are needed with direct comparison to individual treatment models and longer-term outcomes.
This observational comparative effectiveness study used a target trial emulation framework to evaluate the outcomes for patients treated with extended-release naltrexone versus buprenorphine after treatment for medically managed opioid withdrawal (MMOW). Participants were 18 and older and discharged from MMOW in Massachusetts between January 2014 and December 2018. A total of 37,752 unique individuals were included in the study, with 106,052 MMOW discharges. Within the discharge group, there were 14,194 discharges with buprenorphine-naloxone and 4,734 with extended-release naltrexone. The adjusted 24-week cumulative incidence of all-cause mortality was the same between groups at 24 weeks (1.4% for each group); however, the adjusted 24-week cumulative incidence of nonfatal opioid overdose was significantly higher for the naltrexone group (13.9%) compared to the buprenorphine group (11.6%).
This randomized, placebo controlled, double blind trial of mirtazapine for methamphetamine use disorder was conducted in an inpatient psychiatric hospital in Iran. The patients (n=44) were randomized to receive either placebo or mirtazapine at 15 mg daily in week 1 and then 30 mg daily in weeks 2 through 9. Craving scores decreased in both groups but the decrease was significantly greater with mirtazapine than placebo (-18 mirtazapine, -5 placebo, p<.001). Relapse to methamphetamine use occurred in 14% of the mirtazapine group and 46% with placebo; however, the authors noted statistical uncertainty with p=.052. Adverse events more frequent with mirtazapine were drowsiness (5%) and increased appetite (10%). The authors call for larger studies to clarify the effect on relapse.
This is a systematic review and meta-analysis of trials examining the impact of low-dose nicotine products on smoking behavior or smoke exposure. A total of 17 trials were included with 5,500 adult and adolescent participants. No trials found an increase in the number of cigarettes smoked per day or exhaled breath carbon monoxide among participants assigned to very low content cigarettes. Per the meta-analysis, fewer than 1% of people would be expected to increase the number of cigarettes they smoke per day if they were to switch to very-low nicotine content cigarettes. This is relevant in light of the FDA's recent Notice of Proposed Rulemaking to establish a low-nicotine product standard for cigarettes and other combusted tobacco to reduce addictiveness.
In this 2025 cross-sectional survey study, 3,820 8th-, 10th-, and 12th-grade students self-reported their perceived risk of experimental (trying once or twice), occasional, and regular fentanyl use. Researchers found an appreciable portion of adolescents—particularly the younger ones—were not aware of the dangers of fentanyl use. Clinicians, parents, schools, and public education programs all have important roles in communicating the potentially life-threatening risks of fentanyl misuse to adolescents.
- DEA targets synthetic 7-OH products with Schedule I proposal 🔓 Medscape
- 12 ideas for tackling the US alcohol epidemic STAT
- The Drug Enforcement Administration's arbitrary 7-OH ban is not rooted in science 🔓 Reason Foundation
- I smoked cannabis for nearly 20 years. Here's what I wish I knew at 13. The Washington Post
- There's an effective way to treat drug addiction—but you may not like it Los Angeles Times
- MLB players deal with unhinged bettors as league and union secure the gambling bag 🔓 USA Today
- New Jersey adopts major reforms around hospital drug testing of pregnant patients 🔓 The Marshall Project