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ASAM Weekly for March 7, 2023

Mar 8, 2023

This Week in the ASAM Weekly

Governing bodies get creative about addiction. California is looking to grandfather out the sale of tobacco products to anyone born after 2006 (LA Times). Finland drastically cut taxes on alcohol to compete with Estonia (in 2004), setting up an experiment of price reduction on adverse birth outcomes and abortions (Addiction). The DEA -- a federal law enforcement agency -- is re-asserting its role in patient care by (potentially) curtailing access to telehealth buprenorphine treatment (STAT News). Even the American Veterinary Medical Association is engaging with policy makers about xylazine now that it is a concern in the drug-overdose crisis (AVMA).

While an apples-to-oranges comparison was made about California’s policy approach to cannabis vs. tobacco, this week’s lead article professes that not all vaping is the same. In fact, “vaping of CBD [without THC] induces a potent inflammatory response and leads to more pathological changes associated with lung injury than vaping of nicotine.” (Thorax) But maybe policies phasing out tobacco sales could also help reduce infant mortality associated with prenatal tobacco use (eClinical Medicine).

Lastly, a study on overdose mortality and kinship caregiving in Appalachia paints an evidence-based backstory of communities devastated by an overdose crisis (Frontiers in Public Health). It also gives evidence to the frustration advocates feel about the DEA (possibly) making it harder for such communities to access buprenorphine.

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

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

Lead

Not all vaping is the same: differential pulmonary effects of vaping cannabidiol versus nicotine 🔓

Thorax

This in vivo inhalation study in mice and in vitro cytotoxicity experiments with human cells assessed the pulmonary damage-inducing effects of cannabidiol (CBD) or nicotine aerosols emitted from vaping devices. Inhalation of CBD aerosol resulted in greater inflammatory changes, more severe lung damage, and higher oxidative stress compared with nicotine. CBD aerosol also showed higher toxicity to human cells compared with nicotine.

Research and Science

Dose–response association between maternal smoking during pregnancy and the risk of infant death: a nationwide, population-based, retrospective cohort study 🔓

EClinical Medicine

This retrospective cohort study of over 13 million mother-infant pairs examined the dose–response relationship between maternal smoking during each trimester of pregnancy and all-cause and cause-specific infant death. Risk of all-cause infant death and cause-specific infant death by preterm birth, perinatal conditions excluding preterm birth, sudden unexpected infant death, and infection all increased with the degree of cigarette use during the entirety of pregnancy. Mothers who smoked in each trimester of pregnancy tended to be younger, non-Hispanic whites, unmarried, had lower educational level, more parities, fewer prenatal care visits, and more cesarean section and post-neonatal death. Mothers who smoked in the first trimester and then quit were at decreased risk of infant all-cause mortality and sudden unexpected infant death compared with those who smoked during the entire pregnancy. These results indicate that there is no safe level of cigarette use during pregnancy.

The association of lowered alcohol prices with birth outcomes and abortions: A population-based natural experiment

Addiction

Using national registers in Finland, this study used interrupted time-series modeling to assess the associations between birth outcomes and abortions before and after decreased alcohol prices after a tax cut. It also addressed possible heterogeneity of the associations by maternal age and household income. On the population level, lowered alcohol prices were associated with an increase in abortions immediately after the price cut. For birth outcomes, negative associations were observed among women in the lowest income quintile. All changes were strongest immediately after the price cut and attenuated during the course of the following year.

The association between grandparents as caregivers and overdose mortality in Appalachia and non-Appalachia counties 🔓

Frontiers in Public Health

This study used multiple public databases to acquire overdose mortality data, percentage of grandparents serving as caregivers for children, and demographic data for all U.S. counties. Overall, a 1% increase in overdose mortality resulted in a 35% increase in grandparents as caregivers. In Appalachian counties, a 1% increase in overdose mortality resulted in a 56% increase in grandparents as caregivers compared to a 24% increase in non-Appalachian counties. Several factors were associated with grandparents as caregivers: percent non-Hispanic white (p<0.01), rurality (p<0.01), percent uninsured (p=0.01), and teen birth rate (p<0.01). This study notes that children raised by grandparents were more likely to be living in poverty than children raised by their parents and calls for policies to support grandparents and improve the care of children impacted by SUD.

Integrating Alcohol-Related Prevention and Treatment Into Primary Care

JAMA Internal Medicine

Medical care does not always address alcohol use despite its effect on morbidity and mortality. This randomized implementation trial included three strategies: practice facilitation; electronic health record (EHR) decision support; and performance feedback. Outcomes for prevention and treatment included the number of patients who had unhealthy alcohol use and brief intervention documented in the EHR, and the number of patients who had newly diagnosed alcohol use disorder (AUD) and engaged in treatment. Results revealed modest increases in prevention but not in AUD primary care treatment engagement, despite important increases in screening, new diagnoses, and treatment initiation.

Learn More

Episodic foresight is impaired following acute alcohol intoxication 🔓

Journal of Psychopharmacology

Alcohol intoxication disrupts the generation of phenomenological characteristics of future events (a component of episodic foresight) and the execution of directed preparatory behaviors (a component of prospective memory). This study provides the first test of how alcohol intoxication influences the functional application of episodic foresight and the degree to which any observed episodic foresight difficulties associated with alcohol use might reflect broader problems in retrospective memory and executive control. Sex differences were also examined. The study found that episodic foresight was impaired by acute alcohol consumption, with this impairment related to poorer retrospective memory, but not executive control. The negative effects of alcohol intoxication on episodic foresight did not differ as a function of sex.

Deep brain stimulation of the nucleus accumbens in treatment-resistant alcohol use disorder: a double-blind randomized controlled multi-center trial 🔓

Translational Psychiatry

Bilateral deep brain stimulation (DBS) electrodes were implanted by stereotaxis in the nucleus accumbens and a subclavicular pulse generator surgically implanted. Patients with a diagnosis of alcohol use disorder (AUD) for at least 10 years (n=12) were randomly assigned to receive active or sham DBS for 6 months. One patient (in the active DBS group) had continuous abstinence during the first 6 months, but the comparison with the sham DBS group was not statistically significant. The active DBS group had more abstinent days than the sham DBS group (80% v 60% p=0.03) and fewer heavy drinking days (23 days v 47 days p=0.04). The active DBS group had lower alcohol craving scores (p=0.02) and lower anhedonia scores (p=0.01). In this first prospective, double blind, randomized controlled trial of DBS for AUD, the authors conclude that results are suggestive of a beneficial effect of DBS.

Fetal alcohol spectrum disorders 🔓

Nature Reviews Disease Primer

Prenatal alcohol exposure (PAE) is determined by the dose, pattern, timing, and duration of exposure, fetal and maternal genetics, maternal nutrition, concurrent substance use, and epigenetic responses. A safe dose of alcohol use during pregnancy has not been established. PAE can cause fetal alcohol spectrum disorders (FASD), which are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies, and poor growth. FASD are a leading preventable cause of birth defects and developmental disability. The prevalence of FASD in 76 countries is >1% and is high in individuals living in out-of-home care or engaged in justice and mental health systems. The social and economic effects of FASD are profound, but the diagnosis is often missed or delayed and receives little public recognition.