American Society of Addiciton Medicine

ASAM Weekly for September 27, 2022

by Bob Davis

This Week in the ASAM Weekly

Over the last few weeks, we have showcased publications about pregnancy and substance use. This week, our lead adds momentum while reinforcing the detrimental association between mandatory reporting/child abuse policies and a reduction in prenatal and postpartum care in pregnant women who use substances (JAMA Pediatrics). It is a problem needing much more attention. In the associated editorial, Dr. Tucker Edmonds writes of the racist roots of these inequitable policies, the culpability of the US health care system, and the harms done to Black women and children. Unfortunately, the injustices could worsen if legal interpretations of the Dobbs ruling expand to the prosecution of pregnant women who use substances and have miscarriages (The Washington Post). Add to this the high rate of pregnancy-related deaths in the US - over 80% of which are preventable and with the most frequent underlying cause being mental health conditions (22.7%), including substance use (CDC) - and it becomes self-evident that this issue deserves more attention. 

In a new study of mice, rats, and men, spironolactone is re-emerging as a potential therapy for alcohol use disorder (Molecular Psychiatry). A longitudinal study showed that opioids are associated with a global cognitive decline in older adults and the relationship seems to be additive (Journal of American Geriatrics Society). Cannabis leads to an associated psychosis requiring emergency medical attention with greater risks in those who use higher-potency product or with co-occurring mental illness (Translational Psychiatry). The Betel-nut economy is booming and dangerous for human consumption (NEJM).  

Lastly, some important things are happening in the news... Los Angeles Unified School District will be supplying naloxone to all K-12 schools after a sad string of overdoses (NBCLA) and Dr. Brian Hurley encourages the city of Santa Monica to view needle-exchange programs as life-saving exchanges (LA Times). Although news about “bad” doctors vs. the DOJ are often one-sided and un-nuanced, the importance of this CBS headline is the Supreme Court’s decision in the case of Ruan vs. US. Could this help thaw one possible barrier to addiction treatment?

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM

with Co-Editors: Brandon Aden, MD, Debra R. Newman, PA-C, MSPAS, MPH, Jack Woodside, MD, John A. Fromson, MD


Lead Story

Association of State Child Abuse Policies and Mandated Reporting Policies With Prenatal and Postpartum Care Among Women Who Engaged in Substance Use During Pregnancy

JAMA Pediatrics

Certain states have enacted policies that consider substance use during pregnancy as child abuse. In this cross-sectional study of 4,155 pregnant women who engaged in substance use during pregnancy, 33.9% delivered in states with a child abuse policy only, 16.4% in states with a mandated reporting policy only, 32.9% in states with both policies, and 16.8% in states with neither policy. Women who delivered in states with a child abuse policy only, mandated reporting policy only, or both policies initiated prenatal care later, with a reduced chance for adequate prenatal and postnatal care compared with women who delivered in states without these policies. Such policies may deter pregnant people who engage in substance use from receiving the essential care and treatment they deserve.


Call for Reviewers

The Journal of Addiction Medicine is seeking to expand its cadre of manuscript reviewers. We are seeking reviewers with expertise in the following areas: Stimulants, Psychiatric epidemiology, Qualitative methodology, Genetics, Neurology, Emerging substances, Kratom, Novel Psychoactive Substances, Psychedelics, New pharmaceutical treatments, Toxicology, Criminal justice and addiction medicine, Machine Learning, Pain and Palliative Care, Adolescent Medicine, Maternal Child Health, and Behavioral Addictions. View the full opportunity here.


Research and Science 

Prevalence of smoking and smokeless tobacco use during breastfeeding: A cross-sectional secondary data analysis based on 0.32 million sample women in 78 low-income and middle-income 🔓


Low- and middle-income countries (LMICs) contribute to over 80% of global tobacco use. In this study, the authors investigated the impact of tobacco use among breastfeeding women between 2010 and 2020 across 78 LMICs. About one in every 28 breastfeeding women was found to be consuming tobacco. Smokeless tobacco was the main form of tobacco used among breastfeeding women in 25 countries. Smokeless tobacco is often less expensive than cigarettes, more culturally acceptable, viewed as a safe alternative to smoking, and used as medicine to treat common illnesses. Tobacco cessation campaigns during postpartum are needed for the health and wellbeing of women and children in LMICs.


Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis 🔓

Translational Psychiatry

Cannabis can trigger acute cannabis-associated psychotic symptoms (CAPS) in people who use cannabis (PWUC). To assess rates and correlates of CAPS requiring emergency medical treatment, this study analyzed data from an international sample of PWUC (n = 233,475).  It found that 0.47% PWUC reported lifetime occurrence of CAPS.  Higher rates were observed in young individuals; those residing in Denmark; those using predominantly high-potency resin; those mixing cannabis with tobacco; and those with a diagnosis of psychosis, bipolar, anxiety, and depression, compared to individuals without a mental health diagnosis. Taken together, acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC’s lifetime.


Spironolactone as a potential new pharmacotherapy for alcohol use disorder: convergent evidence from rodent and human studies

Molecular Psychiatry

This study describes results from mice, alcohol dependent rats, and humans regarding the effect of spironolactone on alcohol consumption. Mice consumption of an alcohol solution was decreased by spironolactone in a dose dependent manner. Spironolactone also decreased alcohol self-administration in both alcohol dependent and nondependent rats. The human study obtained data from Department of Veterans Affairs records for 10,726 individuals who had been prescribed spironolactone for medical indications and 34,461 matched controls. The VA records alcohol consumption as AUDIT-C scores. AUDIT-C consists of 3 questions about amount and frequency of alcohol use with a range of scores from 0 to 12. AUDIT-C scores decreased in both the spironolactone exposed and the unexposed, however the spironolactone group had a greater decrease (0.5 points in those with the highest baseline AUDIT-C scores). The authors conclude that spironolactone is a promising treatment for AUD.


E-cigarette addiction and harm perception: Does initiation flavor choice matter? 🔓

BMC Public Health

E-cigarette use has increased drastically among adolescents, with 1 in 4 high school students reporting use and 81% starting with non-traditional flavors. The authors in this study examine the relationship between e-cigarette flavor at initiation and predicted addiction and harm perceptions. They did not find a statistically significant difference in perception of harms or predictors of e-cigarette addiction based on initiation flavor type. However, it should be noted that menthol/mint flavor was considered a traditional flavor and these flavors have previously been found to be associated with adolescent smoking behavior. These findings suggest that banning non-traditional flavors alone may not significantly reduce e-cigarette use or development of dependence. 


Learn More

The Seeds of Ignorance — Consequences of a Booming Betel-Nut Economy 🔓

New England Journal of Medicine

In 2022, it remains legal to sell the fibrous seed of the areca palm, commonly known as “betel nut.” People use the substance for a stimulant effect that enhances alertness and, in some, produces a mild euphoria. There were about 600 million betel-nut users worldwide in 2002, which made arecoline from betel nut the fourth most commonly consumed drug after caffeine, nicotine, and alcohol. It is an addictive oral carcinogen, a promoter of nonmalignant odontogenic disease, and associated with adverse pregnancy outcomes. Both betel-nut consumption and the incidence of oral cancer have increased dramatically throughout the Asia–Pacific region in recent decades. Policymakers in these regions have continually neglected to adopt public health initiatives that would address production and use of betel nut, a billion-dollar industry.


Prescription opioids and longitudinal changes in cognitive function in older adults: A population-based observational study

Journal of the American Geriatrics Society

Chronic pain is common among older adults and opioids are frequently prescribed with approximately 10% of adults >60 years of age using opioids. This study utilized the Mayo Clinic Study of Aging to evaluate a potential association between prescription opioids and long-term cognitive function. The authors found an association between opioid prescription and decreased global cognition and the cognitive domains of memory, language, and attention. Further, in the multivariate analysis, each additional prescription was associated with further decline in global cognition. While the associated declines in cognition were small, they were statistically significant. Additional research is needed as it is unclear if there is a casual relationship or if opioid prescriptions may be associated with other conditions linked to cognitive dysfunction. 

Notes from the Field: Nitazene-Related Deaths — Tennessee, 2019–2021 🔓


Nitazines are a group of potent synthetic opioids with some analogs as potent as fentanyl and others greatly exceeding fentanyl’s potency. This study searched Tennessee’s death certificates and toxicology reports for fatal overdoses involving nitazine. Many toxicology panels do not include nitazines and most of the deaths were reported by a single county that also sent samples to the DEA for testing. Nitazine deaths in other counties were likely undercounted. Naloxone was administered in only 23% of cases. Nitazine cases increased from 10 in 2020 to 42 in 2021. The authors hope to increase awareness of nitazines and improve testing and treatment.