American Society of Addiciton Medicine

The ASAM Weekly for May 14th, 2024

by ASAM Weekly Editors

This Week in the ASAM Weekly

Addressing the harms of tobacco (and its derivatives) continues to be tricky. The FDA is considering a standard that lowers nicotine levels in cigarettes essentially rendering them non-addictive, but a perspective from the New England Journal of Medicine explains how such a maneuver could be easily countered. Big tobacco can re-engineer cigarettes while still threatening public health through a number of different tactics such as additives, bronchodilation, enzymatic inhibition, chemical enhancers etc.

With that in mind, we have learned to be suspicious of the tobacco industry (and its derivatives). An invited editorial in Nicotine and Tobacco Research explains how insufficient policies at a professional society allowed for industry influence in its journal- which the authors say enable racist industry tactics to persist and evolve. Similarly, a recent study found that a majority of influencer posts about e-cigarettes are purely promotional- which studies have shown lead to increased vaping among youth- despite the fact that the FDA and even Instagram have explicit rules against this (MedPage Today).

Another challenge of tobacco use is that it is often a confounding factor for cannabis use, especially when studying neonatal outcomes. Now, a large cohort study found that combined cannabis and tobacco use actually have adverse synergistic effects on neonatal morbidity and mortality when compared to either substance alone (JAMA Network Open).

One thing we know for sure about tobacco is that for some people it is so easy to quit, they’ve done it thousands of times. For these non-abstainers, maybe we should think of giving higher doses of pharmacotherapies (JAMA)?

In fact, we should be re-thinking how we approach all non-abstainers within substance use treatment settings and that’s why ASAM drafted the Clinical Considerations for Engagement and Retention of Non-Abstinent Patients in Substance Use Treatment. It’s open to public comment for only a few more weeks so take a look and tell us your thoughts.

(If you’re looking for more information on tobacco cessation, check out ASAM’s Clinical Guidance – Integrating Tobacco Use Disorder Interventions in Addiction Treatment.)

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

ASAM Clinical Considerations for Engagement and Retention of Non-Abstinent Patients in Substance Use Treatment

Beginning today through June 3rd, ASAM has made available for public comment a draft of its Clinical Considerations for Engagement and Retention of Non-Abstinent Patients in Substance Use Treatment document.

Click Here for More Information

Lead Story

Associations of cannabis use, use frequency, and cannabis use disorder with violent behavior among young adults in the United States

International Journal of Drug Policy

An association between cannabis use and violent behavior has previously been reported, so the authors used the 2015-2019 National Survey on Drug Use and Health to better explore this association. In adjusted models, the authors found an increased prevalence of violent behavior among males reporting daily cannabis use with and without cannabis use disorder (CUD) versus no cannabis use. However, there was no increase among males reporting non-daily cannabis use with or without CUD. Researchers found an increase in violent behavior among females reporting non-daily use with or without CUD and daily use with or without CUD. While additional research is needed to better understand this relationship and the sex differences, these findings support the importance of early screening and treatment for CUD.

ASAM Clinical Algorithm Subcommittee 

The ASAM Clinical Algorithm Subcommittee is looking for members to collaborate on refining the 4th Edition clinical algorithms for ASAM Criteria-based assessment tools! Click the link below to learn more and apply.

Applications due May 31, 2024.

Apply Here

Research and Science

Smoking Cessation After Initial Treatment Failure With Varenicline or Nicotine Replacement: A Randomized Clinical Trial


This study provides clinicians with guidance on the best rescue strategies for nonabstinence after initial treatment failure for smoking cessation. Participants receiving varenicline or combination nicotine replacement therapy (CNRT) who were nonabstinent after 6-weeks were rerandomized to continue their medication, increase the dosage, or switch medications for another 6-weeks. Increasing the dosage led to the greatest benefit for those originally taking varenicline, whereas those receiving CNRT benefited similarly from the dosage increase and switching to varenicline, although secondary abstinence measures suggested that the dosage increase may provide longer-term benefit.

Risk of Adverse Neonatal Outcomes After Combined Prenatal Cannabis and Nicotine Exposure 🔓

JAMA Network Open

This study examined whether in utero exposure to cannabis and nicotine in combination is associated with greater adverse outcomes than exposure to either substance alone during pregnancy. In this population-based cohort study of more than 3.1 million pregnant individuals, combined use of cannabis and nicotine products in pregnancy was associated with an increased risk of maternal and neonatal morbidity compared with use of either substance alone, including infant and neonatal death, infants small for gestational age, and preterm delivery. These findings suggest that more effective public health measures and counseling prior to conception and during pregnancy are warranted to mitigate the potential for adverse offspring outcomes from combined prenatal cannabis and nicotine use.

Growing importance of high-volume buprenorphine prescribers in OUD treatment: 2009–2018 🔓

Drug and Alcohol Dependence

The number of prescribers eligible to prescribe buprenorphine (BUP) has increased, but there hasn't been a great increase in patients receiving BUP. This study utilized pharmacy claims data to examine prescriber characteristics between 2009 and 2018. The number of low-volume prescribers (<30 patients per month) was flat until 2017 when advanced practice providers became eligible. The number of high-volume prescribers (>30 patients per month) increased over the study period and by 2018, while only accounting for 10% of all prescribers, they provided 80% of all prescriptions. The subset of very high-volume prescribers (100+ patients per month) accounted for 41.3%. High-volume prescribers were primarily located in urban counties and notably counties with the highest overdose rates. Additional work is still needed to increase access to buprenorphine, particularly in less urban areas. 

A Randomized, Double-Blind, Placebo-Controlled Pilot Trial of the Acute Antisuicidal and Antidepressant Effects of Intranasal (R,S)-Ketamine in Severe Unipolar and Bipolar Depression With and Without Comorbid Alcohol Use Disorder 🔓

The Journal of Clinical Psychiatry

The study assessed the effect of intranasal ketamine on mood and suicidal ideation in patients with a mood disorder (major depression, bipolar, or unipolar) with or without AUD. Patients were randomized to receive intranasal ketamine 50mg (n=17) or intranasal saline (n=11). The ketamine group showed a rapid improvement in depression scores that was not affected by the type of mood disorder or presence or absence of AUD. However, in patients without AUD, improvements in depression and suicidal ideation were correlated (p=.02) but no correlation was observed in patients with comorbid AUD (p=.44). The authors conclude that intranasal ketamine produced rapid improvement in depression without significant effect on suicidal ideation.


Learn More

Reengineering Addiction — The Tobacco Industry’s Potential Response to a Nicotine Standard for Cigarettes

The New England Journal of Medicine

This letter discusses the FDA proposal to limit nicotine content in cigarettes to low levels that would reduce smoking initiation and facilitate smoking cessation. The letter describes numerous tactics that the cigarette industry could use to evade these limits. Modifying the makeup of the tobacco and/or filter could increase nicotine delivery. Making the wrapper with tobacco leaf would make it a filtered cigar not subject to cigarette regulations. Physically encapsulating nicotine could hide it from regulatory analysis but release nicotine when heated. Synthetic nicotine derivatives could boost the effects at the receptor. The industry is interested in 6-methylnicotine, and it is already found in some e-cigarette liquids. Other agonists at the nicotinic acetylcholine receptor could also be added. The authors warn that such tactics need to be considered if nicotine regulations are to be effective.

Commercial Tobacco and Nicotine Industry-Funded Research Has No Place in SRNT and Nicotine & Tobacco Research 🔓

Nicotine and Tobacco Research

In this editorial the authors propose changes to policies at the Society for Research on Nicotine and Tobacco (SNRT) and the Nicotine & Tobacco Research (N&TR) journal to limit the influence of the tobacco industry on science and related harms. They propose including any entity affiliated with manufacture, marketing, or distribution of nicotine and tobacco products in the definition of industry and prohibit individuals receiving any financial support from that industry from participating in SNRT in any way. Further, any individual receiving financial support from the industry should be excluded from N&TR publication, including the submission and review of manuscripts. Finally, procedures to ensure SNRT leadership and members and N&TR team, authors, and reviewers disclose these conflicts need to be put in place. 

Psychosocial and medication interventions to stop or reduce alcohol consumption during pregnancy

Cochrane Database of Systematic Reviews

This review assessed the efficacy of psychosocial interventions and medications to reduce or stop alcohol consumption during pregnancy. It included randomized controlled trials that compared medications or psychosocial interventions, or both, to placebo, no intervention, usual care, or other medications or psychosocial interventions used to reduce or stop alcohol use during pregnancy. The authors found that brief psychosocial interventions may increase the rate of continuous abstinence among pregnant women who report alcohol use during pregnancy.