Wiley: Addiction: Table of Contents

Optimizing outpatient pharmacologic treatment for veterans with alcohol use disorder using an academic detailing approach for primary care providers in the United States Department of Veterans Affairs: A retrospective quasi‐experimental study

Fri, 05 Jun 2026 18:39:43 -0700

Abstract

Background and aims

Although evidence-based medications for alcohol use disorder (AUD) exist, they are alarmingly under-prescribed, particularly for United States (US) veterans. Only 9.5% of veterans who had an alcohol-related overdose death were prescribed a medication for alcohol use disorder (MAUD) in the year prior. Academic detailing (AD), an educational outreach targeting primary care providers (physicians, nurse practitioners and physician assistants), was implemented at the US Department of Veterans Affairs (VA) to improve MAUD prescribing rates among veterans with AUD. This study evaluated the effectiveness of AD outreach to VA primary care providers (PCPs) on MAUD prescribing rates among US veterans with AUD.

Design

We conducted a retrospective, quasi-experimental study using a staggered difference-in-differences approach to evaluate the difference in MAUD prescribing between VA PCPs who received and did not receive an AD outreach at VA between 1 January 2023 and 31 December 2023.

Setting

US Department of Veterans Affairs, the largest integrated national healthcare system in the United States.

Participants

A total of 5153 VA PCPs; 3436 (66.7%) physicians, 1385 (26.9%) nurse practitioners and 332 (6.4%) physician assistants.

Measurements

Clinician-level outpatient MAUD prescribing rates (number of prescriptions per 100 veterans with AUD), which included prescriptions of acamprosate, disulfiram, naltrexone and topiramate. Mean differences in MAUD prescribing rates between PCPs were reported alongside their 95% confidence interval (CI).

Findings

VA PCPs who received an AD encounter were associated with a statistically significant mean increase of 8.10 outpatient MAUD prescriptions per 100 veterans with AUD (95% CI = 5.20–11.01) compared with those who did not receive an AD encounter after adjusting for clinician-level characteristics. This was driven mainly by outpatient prescriptions of topiramate (+4.89; 95% CI = 3.18–6.60), naltrexone (+2.65; 95% CI = 0.90–4.40) and disulfiram (+0.43; 95% CI = 0.03–0.83). In the unadjusted model, there was a statistically significant increase in MAUD prescribing (+1.96; 95% CI = 0.25–3.68), but no statistically significant differences were reported for individual medications.

Conclusions

Between 01 January 2023 and 31 December 2023, primary care providers at the United States Department of Veterans Affairs who received academic detailing outreach were associated with increased medication for alcohol use disorder prescribing rates compared with those who did not receive academic detailing outreach. Academic detailing outreach appears to improve prescribing rates of medication for alcohol use disorder within the US Department of Veterans Affairs for veterans with alcohol use disorder, but careful adjustments of clinician-level characteristics are needed to mitigate potential bias.

Performance‐enhancing drugs and the urgent need for data

Eric Kutscher — Thu, 04 Jun 2026 00:42:11 -0700

Addiction, EarlyView.

Impact of bariatric surgery on alcohol‐use disorder and alcohol‐related liver disease: A retrospective study

Wed, 03 Jun 2026 02:59:09 -0700

Abstract

Background and aims

Increased risk of alcohol dependence is recognised following bariatric surgery. Modified gastrointestinal anatomy and neurohormonal profiles lead to altered alcohol metabolism, peak blood alcohol concentrations and enhanced reward circuits and cravings. For patients with metabolic associated fatty liver disease, bariatric surgery has been shown to reduce liver fibrosis; however, the impact of bariatric surgery on alcohol consumption and consequent liver fibrosis has not been well-characterised using validated measures. This study examined the changes in alcohol consumption patterns, alcohol dependence and validated liver fibrosis measures before and after bariatric surgery.

Design, setting and participants

A retrospective cohort study assessing patients seeking treatment for alcohol problems with a history of gastric sleeve (GS) or Roux-en-Y Gastric Bypass (RYGB) in a quaternary hospital in Brisbane, Australia.

Measurements

Validated measures of alcohol dependence [Alcohol Use Disorders Identification Test (AUDIT) and brief Michigan Alcohol Screening Test (bMAST)] and non-invasive liver fibrosis (FIB4 and APRI) were compared pre- and post-surgery.

Findings

Twenty patients were identified with prior GS and 10 patients with RYGB. Following bariatric surgery, body mass index was reduced by 14.5 (±9.39) kg/m². Metabolic co-morbidities were less frequent post-surgery. Pre-surgery, the mean AUDIT score was 10.2 ± 8.9, with 9 patients having scores indicative of alcohol dependence. Mean AUDIT increased statistically significantly post-surgery (18.1, standard deviation ±11.4; P < 0.001) with 29 patients meeting criteria for alcohol dependence. AUDIT components relating to both consumption (volume, frequency) and harmful consequences of alcohol increased following surgery. Despite surgery lowering metabolic liver fibrosis risk, worsened liver fibrosis was observed [mean FIB4 (0.98 ± 1.8) and APRI (0.41 ± 0.83) increased; P < 0.05].

Conclusion

Within a cohort of adults seeking treatment for alcohol problems, increases in alcohol consumption and alcohol-related harm were observed following bariatric surgery. Despite improvement in risk factors for metabolic-associated fatty liver disease after surgery, non-invasive markers for hepatic fibrosis worsened, likely in the setting of harmful alcohol intake and associated liver injury. This supports the role of bariatric surgery pre-operative assessment and post-operative follow-up to identify and manage alcohol-related problems and associated liver disease risk.

Keeping stimulant‐induced psychosis in sight

Shalini Arunogiri — Tue, 02 Jun 2026 03:30:29 -0700

Addiction, EarlyView.

Comparative effectiveness of alternative times to opioid agonist treatment taper initiation on taper completion and all‐cause mortality among people with opioid use disorder: A retrospective population‐based target trial emulation study in British Columbia, Canada, 2010–2020

Tue, 02 Jun 2026 03:27:28 -0700

Abstract

Background and aims

Opioid use disorder (OUD) treatment guidelines worldwide recommend opioid agonist treatment (OAT) as a long-term, potentially indefinite treatment for managing OUD. However, many individuals express a strong interest in eventually tapering fully off treatment. Current clinical practice guidelines offer relatively limited guidance or evidence on the appropriate timing to initiate a taper. We aimed to determine the safety and comparative effectiveness of different times from completion of OAT induction at which tapering could be considered to maximize the likelihood of taper completion and minimize the risk of mortality.

Design

Population-based retrospective observational study and target trial emulation based on nine linked administrative health databases.

Setting

British Columbia, Canada, from 1 January 2010 to 17 March 2020.

Participants

Individuals (identified via linkage of nine provincial health administrative databases) completing OAT induction with methadone or buprenorphine/naloxone who were ≥18 years of age with no known pregnancy, no history of cancer or palliative care and not currently incarcerated. We executed both incident-user (no OAT experiences) and prevalent-new-user (no OAT within the past month) analyses.

Intervention and comparator

The time between completed OAT induction and taper initiation: <3 months, 3–6 months, 6–12 months, compared with 12–48 months.

Measurements

The primary outcomes were completed taper (reaching a final daily dose of ≤5 mg/day for methadone, or ≤2 mg/0.5 mg/day for buprenorphine/naloxone) and all-cause mortality. A clone-censor-weight approach was used to adjust for informative censoring and balance baseline characteristics between the groups. Logistic regression and pooled logistic regression models were used to estimate odds ratios (ORs) for completed taper and hazard ratios (HRs) for all-cause mortality, respectively, each with 95% compatibility (‘confidence’) intervals.

Findings

We included 17 726 incident users (buprenorphine/naloxone: 36.9%) and 49 515 treatment episodes (buprenorphine/naloxone: 31.2%) from 31 231 prevalent new users who completed induction in the analyses. Among prevalent new users, beginning tapering within 3 months, between 3 and 6 months and between 6 and 12 months of completing induction was associated with an increased likelihood of completed taper [methadone: <3 months: adjusted odds ratio (aOR) = 3.09, 95% compatibility interval (95% CI) = 2.58–3.68; buprenorphine/naloxone: <3 months: aOR = 6.90, 95% CI = 5.19–9.16] but a higher risk of mortality [methadone: <3 months: adjusted hazard ratio (aHR) = 1.18, 95% CI = 1.12–1.25; buprenorphine/naloxone: <3 months: aHR = 1.12, 95% CI = 1.05–1.19], compared with initiating a taper between 12 and 48 months. Similar results were found among incident users.

Conclusions

Although initiating early tapering off opioid agonist treatment may be associated with a greater likelihood of taper completion, this practice also increases the risk of mortality.

Charting the decline of the fourth wave: US overdose deaths by race, ethnicity and substance involvement

Tue, 02 Jun 2026 01:00:22 -0700

Abstract

Aims

To characterize decreases in overdose death rates in the United States (US) between 2023 and 2024 by race/ethnicity, and substance involvement.

Design

Population-based study of national death records accessed via the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) platform using an underlying cause of death approach.

Setting

US.

Participants/cases

All individuals who died from drug overdose between January 1999 and December 2024.

Measurements

Annual overdose deaths per 100 000 population. Year of occurrence of overdose death, substance involvement, race/ethnicity of decedents.

Findings

After many years of increases, the US overdose death rate dropped 24.4% between 2023 and 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulant involvement). The fourth wave of the US overdose crisis—defined by deaths involving fentanyl together with stimulants—declined for the first time in 2024. Despite overall decreases, deaths involving stimulants without fentanyl and deaths involving xylazine continued to represent a growing fraction of overdose fatalities. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023–2024, falling by 29.3% but remaining elevated at 36.0 per 100 000, 1.51 times higher than the national average of 23.7 per 100 000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose death rates rate in 2024, at 50.8 per 100 000, 2.15 times the national average rate, and experienced a below-average relative decrease of 20.1%.

Conclusions

All four previously defined waves of the US overdose crisis appear to be in decline, as deaths involving illicit fentanyl, with and without stimulants, dropped sharply between 2023 and 2024. Concurrently, the fraction of overdose deaths involving stimulants without fentanyl and those involving xylazine continued to increase. While racial disparities in drug overdose death rates narrowed slightly during this period, large gaps remain, with the highest overdose death rates among American Indian, Alaska Native, and Black individuals.

Tobacco and cannabis use in the young ‘Not in Employment, Education or Training’ population: A systematic review and meta‐analysis

Mon, 01 Jun 2026 19:30:50 -0700

Abstract

Background and aims

NEET (Not in Employment, Education or Training) youth represent a vulnerable population from a public health perspective, facing multiple health challenges, including elevated substance use. Tobacco and cannabis are the most commonly used psychoactive substances among young people, with early initiation associated with long-term health and social consequences. While evidence suggests associations between NEET status and substance use, data remain limited regarding patterns of use and potential variations across different NEET profiles. This study aimed to characterise tobacco and cannabis use within the NEET population, taking into account the diversity of profiles, and to compare it with that of the general population, including employed youth and students, in order to inform targeted prevention strategies.

Methods

A systematic review and meta-analysis included observational studies examining tobacco and cannabis use among NEET youth aged 15–29 years. A search was conducted for observational studies available on PubMed, PsycINFO, Cairn and Web of Science databases and published between 1999 and 2025. Analyses studied the variations in use among NEET profiles and compared NEET against employed youth, student and general population controls. Random-effects models generated pooled crude odds ratios. Sensitivity and subgroup analyses were conducted based on study quality, gender and type of comparison population.

Results

Twenty-five studies were included and analysed, including a total of 91 085 individuals. A statistically significant association between NEET status and both tobacco use [odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.46–2.53] and current cannabis use (OR = 2.14, 95% CI = 1.68–2.71) was found. Current smoking was statistically significantly more prevalent among NEET than among students (OR = 3.05, 95% CI = 2.31–4.03), but not statistically significantly different compared with young workers (OR = 1.10, 95% CI = 0.91–1.34). NEET demonstrated statistically significantly higher cannabis use compared with both students (OR = 1.81, 95% CI = 1.34–2.44) and workers (OR = 1.67, 95% CI = 1.21–2.31). A higher prevalence of cannabis use disorder among young people with NEET status (31.93%) was observed compared with their non-NEET peers (12.12%), but no statistically significant association was found.

Conclusions

Youth Not in Employment, Education or Training (NEET) appear to show higher tobacco and cannabis use compared with their peers. Given these findings, targeted prevention strategies addressing substance use in NEET populations are essential to reduce social health inequities.

Can Thailand replace a commercialised cannabis market for adult use with a medical prescription model?

Mon, 01 Jun 2026 00:19:58 -0700

Addiction, EarlyView.

#NoIDVape: A content analysis of illicit vape messaging in young people's information sources

Sun, 31 May 2026 16:01:18 -0700

Abstract

Background and aims

In recent years, the increased prevalence of youth vaping in the United Kingdom (UK) may have coincided with a proliferation in the use of ‘illicit’ (unregulated) vapes. Media or educational content about illicit vaping aimed at young people is scarce and poorly understood. This study aimed to systematically assess the content of both TikTok videos and educational resources relating to illicit vaping.

Methods

A systematically conducted analysis of educational and social media resources. Manual searches were conducted in the UK to collect URLs and metadata for publicly available TikTok videos using eight illicit vaping-related hashtags. Video content was coded across inductively derived thematic domains. Educational resources were collected via relevant search terms on Google; illicit vape content was appraised across five domains and the quality of each resource was assessed.

Results

A total of 58 TikTok videos were categorised across nine thematic domains. The most prevalent themes were ‘Apathy Towards Law’ (57%), ‘Entertain/Humour’ (50%) and ‘Sub-culture and Shared Experience’ (50%), generating a combined total of 21 million likes. Educational resources were rated as ‘good’ quality overall (56%) but underperformed in domains related to ‘Illicit Vapes Health Risk Depiction’ and ‘Relevance and Appeal to Youth’. In contrast to the ‘homemade’, ‘entertaining’ and sometimes ‘glamourising’ presentation of the TikTok videos, educational resources adopted a serious tone and were often disengaging.

Conclusions

Illicit vaping content differs between TikTok videos and educational resources, exhibiting differences in sentiment, information and youth appeal. TikTok videos typically receive high engagement and frequently depict themes of apathy towards the law, entertainment and shared experience. Educational resources are generally of good quality but contain limited information on illicit vape health risks and lack youth relevance.

Beyond treatment response: Injection‐site reactions as part of the extended‐release buprenorphine experience

Julien Cabé, Georges Brousse — Sat, 30 May 2026 00:05:18 -0700

Addiction, EarlyView.

Commentary on Norström and Leifman: A welcome contribution and an invitation to further research

Ingeborg Rossow — Fri, 29 May 2026 23:54:39 -0700

Addiction, EarlyView.

Enhancing recovery science: From theory to life stage and context, to subpopulations and new paradigmatic thinking

John F. Kelly, William L. White — Thu, 28 May 2026 23:10:22 -0700

Addiction, EarlyView.

Addiction, Inc.: Medication‐assisted treatment and America's forgotten war on drugs. Emily Dufton, Chicago, Illinois, USA: University of Chicago Press, 2026. ISBN: 9780226750064

Kathleen J. Frydl — Thu, 28 May 2026 06:25:11 -0700

Addiction, EarlyView.

Commentary on Nieto et al.: The heterogeneity of drug craving and considerations as a treatment endpoint

Justin C. Strickland, Cecilia L. Bergeria, Samuel F. Acuff — Thu, 28 May 2026 06:15:09 -0700

Addiction, EarlyView.

Will social media bans reduce the amount of substance use‐related content to which young people are exposed?

Benjamin Riordan, Megan Strowger, Emmanuel Kuntsche, Taylor Winter — Wed, 27 May 2026 20:10:49 -0700

Addiction, EarlyView.

Associations between modes of cannabis use and cannabis use disorder: Evidence from the 2022 to 2023 United States National Survey on Drug Use and Health

Tue, 26 May 2026 01:26:42 -0700

Abstract

Background and Aims

With expanding cannabis legalization, normalization, and diversifying products and delivery methods in the United States (US), cannabis use disorder (CUD) prevalence is rising. Various modes of cannabis use may influence pharmacokinetics, usage patterns, and harm, affecting CUD risk. We measured associations between modes of cannabis use, including multi-modal patterns, and CUD prevalence and severity.

Design and Setting

This cross-sectional study analyzed data from a nationally representative sample of US adults using the 2022–2023 National Survey on Drug Use and Health (NSDUH) data. Multivariable logistic regression analyses were employed to estimate the association between modes of cannabis use and past-year CUD, adjusting for potential confounders and covariates. Analyses were stratified by sex, age, and cannabis use frequency. Among multi-modal users, common combinations and their associations with CUD were further examined.

Participants/Cases

Respondents 18 years or older who reported past-year cannabis use (unweighted n = 25 549; weighted N = 58 850 309).

Measurements

Exposure of interest was the mode of cannabis use, primarily categorized as smoke-only, vape-only, oral/mucosal-only, dab-only, topicals-only, and multi-modal (≥ two modes). The outcome variable was CUD in the past year, and CUD severity, based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Covariates included age, sex, race/ethnicity, income, education, state cannabis law status, age of cannabis initiation, cannabis use motive, frequency of use, perceived risk of smoking cannabis, illicit drug use, past year mental illness, nicotine dependence, and alcohol use disorder.

Findings

Of the total past-year cannabis users, 53.9% reported multi-modal cannabis use. Overall, CUD prevalence was 30.3%, ranging from 4.4% among oral/mucosal-only to 40.5% among multi-modal, and 28.9% among dab-only users (p < 0.0001). Moderate-to-severe CUD affected 13.2% of all users and was concentrated among multi-modal and dab-only users. In multivariable regression, multi-modal users had fourfold higher odds of CUD (adjusted odds ratio [AOR] = 4.14; 95% confidence interval [CI]: 2.91–5.90). Elevated odds were also observed among smoke-only (AOR = 2.98; 95% CI: 2.02–4.39) and vape/dab-only users (AOR = 1.89; 95% CI: 1.09–3.29), compared with oral/mucosal-only users. Analyses of multi-modal combinations showed the highest CUD odds among those using smoke + vape + oral/mucosal + dab (AOR = 19.74; 95% CI: 9.11–42.75), compared with oral/mucosal + topicals users.

Conclusions

In the United States, modes of cannabis use appear to be statistically significantly associated with prevalence and severity of cannabis use disorder, with multi-modal and inhaled routes conferring the greatest risk. Findings underscore the importance of considering mode of use alongside frequency and potency in clinical assessment, prevention, and policy strategies aimed at reducing cannabis-related harms.

Predictive validity of Alcohol Use Disorder Identification Test – Consumption (AUDIT‐C) for register‐based alcohol‐attributable events among general‐population men and women of different ages

Mon, 25 May 2026 18:46:56 -0700

Abstract

Background and aims

Originally developed for clinical screening for hazardous alcohol use, the Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) is also widely used in epidemiological research and monitoring. However, its cutoff values may not suit all purposes, and evidence on its predictive validity is limited. We examined how AUDIT-C scores relate to subsequent register-based alcohol-attributable events across age and sex and identified optimal thresholds for predicting these outcomes.

Design

Five general population surveys conducted in 2011–2017, linked to nationwide registers with follow-up until the end of 2023 (total follow-up 879 964 person-years).

Setting

Nationwide, Finland.

Participants

Adults aged ≥20 years (n = 103 567).

Measurements

AUDIT-C to assess exposure. Outcome: incident alcohol-attributable events in any of the registers capturing care, deaths and prescription medicines (n = 1444).

Findings

The hazard of register-based alcohol-attributable events increased approximately exponentially with increasing AUDIT-C score. It rose more strongly among women than men [hazard ratio (HR) = 1.61, 95% confidence interval (CI) = 1.55–1.67 for women; HR = 1.45, 95% CI = 1.40–1.49 for men; P < 0.001 for the sex × AUDIT-C interaction]. The risk of alcohol-attributable events was statistically significantly raised at 2 points among women and 3 points among men with 1 point as a reference level. The suggested optimal cutoff values were 2 points for women aged ≥80, 3 points for women aged 65–79 and men aged ≥80, 5 points for women aged 20–64 and men aged 65–79 and 6 points for men aged 20–64.

Conclusions

Using Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) scores, optimal cutoff values for predicting alcohol-attributable harm may differ by age and sex, with lower cutoffs for older individuals and women. The ≥65 age group appears to be heterogeneous with regard to vulnerability to alcohol-attributable harm, which should be considered when establishing cutoffs or guidelines for alcohol use.

Response to Crockford et al.: Healthcare utilization and mortality after overdose prevention site closure: A linked cohort analysis using segmented difference‐in‐differences time series

Nathaniel Day, Shelly Vik, Robert Tanguay, Nickie Mathew, Anees Bahji — Thu, 21 May 2026 17:29:45 -0700

Addiction, EarlyView.

Change of substance‐related hospitalisation in adolescents after cannabis legalisation in Thailand in 2022

Thu, 21 May 2026 17:19:55 -0700

Abstract

Background and aims

On 9 June 2022, Thailand changed its cannabis legislation, expanding access to individuals aged >18 years. Evidence suggests that such changes could increase the risk of cannabis use and related harms, and could influence patterns of use of other substances among adolescents. This study measured the potential impact of these legislative changes on adolescent substance-related hospital admissions.

Design

An interrupted time-series study to assess the impact of cannabis legalisation on substance-related hospitalisations using anonymised admission records from the Thai Health Information Portal.

Setting

Nationwide study in Thailand spanning from 1 October 2016 to 30 September 2023, with 9 June 2022 marking cannabis legalisation.

Participants/cases

Adolescents aged 10–19 years in Thailand.

Measurements

Based on International Classification of Diseases, 10th Revision diagnostic codes, hospitalisation records were classified as relevant or irrelevant to each of eight predefined substance categories: stimulants (excluding cocaine), alcohol, cannabis, sedatives (including opioids and narcotics), volatile solvents, nicotine, hallucinogens and cocaine.

Findings

There were an additional 25.5 weekly cannabis-related hospitalisations (95% prediction interval = 23.5–27.2) compared with counterfactual predictions, resulting in 1762 excess cases over the 68-week post-legalisation period. Statistically significant excess admissions were also observed for stimulants, nicotine, volatile solvents and hallucinogens, corresponding to additional admissions of 9.1, 1.4, 0.5 and 0.5 per week, respectively (95% prediction intervals = 0.3–15.4, 0.4–2.1, 0.3–0.7 and 0.2–0.7, respectively). No statistically significant changes were observed for alcohol-, sedative- or cocaine-related hospitalisations.

Conclusions

Cannabis legalisation in Thailand was followed by a marked rise in adolescent hospitalisations related to cannabis, alongside an increase in stimulant-, nicotine-, volatile solvent- and hallucinogen-related hospitalizations. These findings highlight the potential unintended consequences of cannabis legalisation in Thailand and underscore the need for preventive strategies to reduce adolescent exposure and related harm.

Commentary on Zhu et al.: Nitazenes—Tracking a moving target from linked United States databases

Christophe P. Stove, Marthe M. Vandeputte — Thu, 21 May 2026 01:28:58 -0700

Addiction, EarlyView.

The effect of higher versus lower wattage e‐cigarettes on smoking: A randomized controlled trial

Thu, 21 May 2026 00:00:00 -0700

Abstract

Aims

To assess whether higher wattage e-cigarettes (HWe), with improved nicotine delivery, enhance complete substitution compared with lower wattage e-cigarettes (LWe) and whether complete switching lowers exposure to a cigarette-derived lung carcinogen, using urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) as a biomarker.

Design

A 3-arm randomized controlled trial with a 12-week treatment period and follow-ups at 26 and 52 weeks. Participants were enrolled from June 2017 to December 2022, with all visits completed by March 2023.

Setting

Academic medical centers in the United States.

Participants

372 adults who smoked and were not interested in quitting [mean age = 40 years; standard deviation (SD) = 11.0; 63% female; mean cigarettes per day = 17; SD = 8.9] were randomized and comprised the analytic sample.

Intervention

A 12-week supply of HWe, LWe or usual brand cigarettes (UBC).

Measurements

The primary outcome was between-group differences in complete substitution rates at week 12, defined as self-reported smoking of 1 or fewer cigarettes in the past 7 days [confirmed by exhaled carbon monoxide (eCO) < 4 ppm], with missing data imputed as smoking, and self-reported use of e-cigarettes during the 7-day period. Additional outcomes included urinary NNAL through week 12.

Findings

At 12 weeks, complete substitution rates were 6.0% (8 of 134) with HWe and 9.0% (12 of 133) with LWe, with no statistically significant between-group difference. Complete substitution rates were 3.7% (HWe) vs. 9.0% (LWe) at 26 weeks, and 4.5% vs. 5.3% at 52 weeks, with no statistically significant between-group differences. Among those who completely switched, mean NNAL levels decreased over 12 weeks with both LWe [mean decrease: 2.4 pmol/mg creatinine; 95% confidence interval (CI) = 1.2–3.7; P = 0.002] and HWe (mean decrease: 2.3 pmol/mg creatinine; 95% CI = 1.1–3.6; P = 0.002).

Conclusions

Provision of higher and lower wattage e-cigarettes to adults who smoked and were not interested in quitting resulted in comparable substitution rates. Complete switching from cigarettes to higher and lower wattage e-cigarettes reduced urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol.

Trial Registration: NCT03113136 (ClinicalTrials.gov).

Predictive value of real‐time memory tests in identifying alcohol‐induced blackouts in situ

Wed, 20 May 2026 06:00:33 -0700

Abstract

Background and aims

Memory loss from alcohol use (‘blackout’) is a prevalent and costly indicator of substance-related harm. While alcohol-induced blackouts can be assessed retrospectively via self-report, no tool exists to identify blackouts objectively in real time, hindering progress in research as well as intervention efforts. This study tested the feasibility and diagnostic accuracy of real-time memory tasks in identifying alcohol-induced blackouts in situ.

Design

Prospective diagnostic study.

Setting

United States.

Participants

Young adults (18–30 years of age; n = 63) reporting recurrent memory loss as a result of alcohol use were recruited from across the United States between December 2022 and January 2024.

Measurements

Participants completed a baseline survey and orientation interview, followed by 30 days of ecological momentary assessments (EMA). EMA included recall and recognition tests for visual stimuli during drinking events (index tests) and subsequent self-reports of blackout (reference standard). At the end of the protocol, participants also completed a Timeline Followback interview of blackout events during the assessment period. Primary outcomes, which were specified prior to data collection, were (a) feasibility of memory task completion during drinking events and (b) diagnostic accuracy of memory tasks in identifying blackout at the event level. Data were analyzed using Bayesian logistic multilevel models.

Findings

Of the 63 participants included [mean age = 23.2, standard deviation (SD) = 3.3; 78% female, 51% White], 38 (60%) self-reported a blackout during the assessment protocol. On average, participants completed 85% of memory tests prompted (SD = 16.42). Within days, both greater-than-average number of drinks [odds ratio (OR) = 1.74; 95% confidence interval (CI) = 1.41–2.19] and failure of 1 + recall memory test (OR = 15.53; 95% CI = 5.96–36.27) were associated with increased odds of blackout. In model-predicted probabilities, blackout probability was ~0.01 if a person consumed their average number of drinks, ~0.21 if they had five more drinks than average and ~0.34 if they failed 1 + recall test. Participants self-reported blackout on 39% of the days that they failed 1 + recall memory test (positive predictive value; 95% CI = 30–49); however, they reported not having a blackout on 92% of days that they correctly recalled all memory tests (negative predictive value; 95% CI = 89–95).

Conclusions

Objective measures of alcohol-induced blackout can be implemented in real-life contexts. Failing a visual memory test while intoxicated is not necessarily indicative of blackout; however, correct recall indicates that blackout is highly unlikely.

Effects of nicotine concentration and pH on nicotine pouch appeal and sensory experience: A randomized experimental study

Wed, 20 May 2026 02:59:56 -0700

Abstract

Background and aims

Understanding key product characteristics of oral nicotine pouches (ONPs), an emerging nicotine product category, is essential to developing evidence-based regulations that address ONP use among young populations. This experimental trial assessed the effects of variations in nicotine concentration and pH in NPs on two behavioral outcomes of regulatory interest: sensory attributes and appeal.

Design and Intervention

We conducted an in-person, double-blind, within-subject randomized experiment involving standardized self-administration of 4 commercially available NPs (drawn from a pool of 20 ZYN and on! products) varying in nicotine strength (high: 6–8 mg vs. low: 3–4 mg) and pH (high: 8.5–9.3 vs. low: 7.6–8.0). Experimental conditions were not mutually exclusive (i.e., NP with a high pH could either have high or low nicotine concentration, or vice versa), and NPs were randomly assigned without replacement to ensure participants did not receive the same product more than once in each condition.

Setting

Los Angeles metropolitan area in California, United States (U.S.).

Participants

Seventy-three young adults (21–35 years, mean[standard deviation] = 23.7[3.1] years; 87.7% males, 49.3% White) who currently use NPs were recruited between October 2024 and July 2025.

Measurements

Participant rated ONP appeal and sensory attributes (sweetness, smoothness, bitterness, harshness) on 0 (‘not at all’) to 100 (‘extremely’) scales. Repeated-measures random-intercept models assessed the effects of nicotine concentration and pH on the appeal and sensory attributes.

Findings

In the sample, high (vs. low) nicotine strength produced statistically significant lower ratings of appeal (b = −8.75, 95% confidence interval [CI] = −15.41, −2.08) and smoothness (b = −7.72, 95% CI = -14.01, −1.44) and higher harshness ratings (b = 7.21, 95% CI = 1.07, 13.36). No statistically significant linear effects of pH on appeal and sensory attributes were observed. Quadratic analyses revealed non-linear associations whereby ONP appeal and sweetness declined at both tails of the pH distribution (inverted U-shape). Statistically significant interactions between nicotine concentration and quadratic pH were observed for appeal and bitterness with stronger quadratic pH effects in high (vs. low) ONPs. In addition, statistically significant pH–sex interactions showed stronger quadratic effects in females (vs. males) for appeal and bitterness.

Conclusions

In this double-blind randomized experiment among young adult oral nicotine pouch (NP) users in the United States, exposure to NPs with [1] higher vs. lower nicotine concentrations produced lower appeal and smoothness and greater harshness; [2] varying pH produced non-linear effects, such that appeal and palatability rose at moderate pH levels and then declined at high pH levels, particularly for high-nicotine NPs and among females.

Day‐level associations between protective behavioral strategies and alcohol consequences among young adults enrolled vs. not enrolled in college

Fri, 15 May 2026 21:44:41 -0700

Abstract

Background and aims

Protective behavioral strategies (PBS) are designed to minimize negative alcohol-related consequences. They include limiting/stopping, manner-of-drinking (e.g. avoiding shots or drinking games) and serious harm reduction strategies. This secondary analysis measured day-level, within-person associations between PBS and alcohol-related consequences (including alcohol-induced blackout) among young adults enrolled and not enrolled in college.

Design

Observational study using ambulatory assessments each morning for 30 days.

Setting

United States.

Participants

Young adults (n = 153, 35% male, 58% White, mean age = 22 y) with a history of alcohol-induced blackout. Fifty-nine participants (39%) were enrolled in college.

Measurements

Participants completed an orientation interview, baseline self-report measures and 30 days of prospective morning reports. Multilevel logistic regression was used to analyze data.

Findings

Within persons, participants had lower odds of experiencing any same-day alcohol-related consequence [odds ratio (OR) = 0.36; 95% confidence interval (CI) = 0.25–0.53], including blackout (OR = 0.24; 95% CI = 0.14–0.42) on days they used manner-of-drinking strategies compared with days they did not. Conversely, experiencing an alcohol-related consequence was not associated with use of manner-of-drinking (OR = 1.06; 95% CI = 0.76–1.48) or limiting/stopping (OR = 1.06; 95% CI = 0.76–1.49) strategies on the next drinking day. College enrollment did not moderate any of the associations.

Conclusions

Manner-of-drinking strategies appear to reduce the odds of alcohol-related harm at the event level among young adults in the United States, whether or not they are enrolled in college. We speculate that limiting strategies (e.g. counting drinks) appear less effective because they are more difficult to implement in real-life drinking contexts.

Stimulant‐induced psychosis requires the same clinical priority as other psychotic disorders

Solja Niemelä — Thu, 14 May 2026 21:58:43 -0700

Addiction, EarlyView.

Characteristics of deaths due to drug‐related causes among individuals recently released from prison in the United Kingdom, 1997–2025

Emmert Roberts, John Strang, Caroline Copeland — Thu, 14 May 2026 21:46:00 -0700

Abstract

Background and aims

There has been an extensive literature describing the elevated risk of drug-related death following an individual's release from prison; however, few previous studies have reported nationally representative samples or provided granular detail as to which individual drugs were deemed implicated in death. We aimed to determine the (1) case characteristics, (2) circumstances of death and (3) type of implicated drugs among individuals recently released from prison and dying due to drug-related causes, stratified by the length of time an individual had been released prior to death. We additionally aimed to determine any changes in the number of deaths and the percentage of deaths in which individual drugs were implicated over time.

Design

Retrospective cohort study.

Setting

Coronial records submitted voluntarily to the observational cohort National Programme on Substance Use Mortality (NPSUM) in the United Kingdom (UK), 1997–2025.

Cases

Decedents who were recently released from prison up to one month prior to their death due to a drug-related cause.

Measurements

Information was available on decedent sociodemographics, characteristics of death and drugs implicated in death.

Findings

A total of 597 decedents were found to have died due to a drug-related cause following recent release from prison. Where records reported the exact timeframe between prison release and death (n = 309), 140 were reported to have died within two days of release, 81 between two days and one week and 88 between one week and one month. There was a statistically significant average annual percentage decrease of −3.9% [95% confidence interval (CI) = −6.6% to −1.0%, P = 0.006] of deaths following recent prison release within the NPSUM population over the studied timeframe. Overall, decedents were predominantly male (n = 547, 91.6%), of White ethnicity (n = 410, 68.7%) and had a mean age of 34.2 years (standard deviation 8.8; range 16–71). Accidental poisoning was the most common direct cause of death (n = 433, 72.5%), with opioids the most common class of implicated drug, involved in more than 90% of fatalities (n = 545, 91.3%).

Conclusions

Over the past three decades relative to the overall UK National Programme on Substance Use Mortality cohort of deaths due to drug-related causes, there have been substantial and reducing numbers of drug-related fatalities among individuals recently released from prison. Accidental poisoning was the direct cause of death in almost three quarters of cases from 1997 to 2025, and opioids were consistently implicated in over 90% of fatalities.

A review of the relationship between dimensions of alcohol consumption and the burden of disease: 2026 update including Mendelian randomisation studies

Wed, 13 May 2026 21:01:01 -0700

Abstract

Background and aims

Evidence on the causal impact and corresponding risk relationships between dimensions of alcohol consumption and health outcomes continues to evolve, with some contradictory findings across study designs. This review aimed to update current knowledge on causality and risk relationships to inform global and national comparative risk assessments for alcohol.

Methods

Fully alcohol-attributable conditions were identified using International Classification of Diseases (ICD) 10th and 11th revision codes. We conducted a scoping review of meta-analyses of cohort studies on average consumption and health outcomes (56 reviews), a systematic review of Mendelian randomisation (MR) studies on alcohol and ischaemic heart disease (IHD; 20 studies), and narrative syntheses on injuries, biological pathways, and reversibility of effects.

Results

ICD-11 provides more detailed categories, defining 62 fully alcohol-attributable conditions compared with 48 in ICD-10. Meta-analyses support monotonic increasing dose–response relationships between average consumption and most attributable health outcomes within infectious diseases, cardiovascular diseases, cancers, and digestive diseases. Relationships are J-shaped for IHD, ischaemic stroke, and type 2 diabetes, with lower risk at low-to-moderate consumption (generally only without heavy episodic drinking). For dementia, heavy drinking is harmful and, among non-heavy drinkers, relationships are age-specific. MR evidence for IHD largely suggested null or harmful relationships, but only three studies tested non-linear effects. In our view, the overall synthesis indicates that current MR evidence is insufficient to refute a J-shaped relationship for IHD. Injury risk is driven primarily by acute intoxication and includes substantial harm to others. Acute risks are reversible with reductions in drinking or abstention, whereas many chronic disease processes are only partly reversible.

Conclusions

Epidemiological evidence to inform comparative risk assessments for alcohol is comprehensive, but prone to major limitations. Triangulation, alongside biological plausibility, can strengthen synthesis across cohort and Mendelian randomisation studies, and the target trial framework can help future studies avoid design-induced biases. Comparative risk assessments with ischaemic heart disease should, at this point, prioritise evidence from cohort studies.

Health and economic impact of universal screening and management of alcohol use disorders in India: An economic modelling study

Wed, 13 May 2026 05:09:56 -0700

Abstract

Aim

The study assessed the health and economic implications as well as the cost-utility of implementing universal alcohol use disorder (AUD) screening in 15–74 years population at the primary healthcare level compared with the current practice of diagnosis and management of symptomatic AUD patients seeking formal healthcare.

Design

Model-based cost-utility analysis using a hybrid model comprising a decision tree and lifetime age- and gender-specific Markov models for alcohol attributable conditions, including road traffic accident injuries, alcohol-related liver disease and head and neck cancers. The analysis was undertaken from both an abridged societal (consideration of direct cost of care) and a societal (consideration of direct and indirect costs) perspective.

Setting

India (national and sub-national level analysis).

Participants

15–74 years population segregated by gender.

Interventions and comparators

The intervention was 10-year annual population-based screening for alcohol use disorders using alcohol use disorder identification test by community health workers at primary care facilities. The comparator was ‘usual care’ scenario of diagnosis and management of symptomatic AUD patients, considering care seeking patterns in India.

Measurements

Differences in life years, quality-adjusted life years (QALYs), alcohol attributable deaths and morbidities, direct costs and indirect costs in the comparative scenarios, along with incremental cost-utility ratio (ICUR), benefit–cost ratio and net monetary benefit. ICUR was evaluated using the per-capita gross domestic product (GDP) threshold of ₹171 498 (US$2182), as per Indian economic evaluation guidelines. Probabilistic and deterministic sensitivity analysis was conducted to identify the parameters that are likely to have an impact on efficiency of the screening programme.

Findings

The AUD universal screening programme was associated with a gain of 71.16 million QALYs at population level, with approximately one-fourth reduction in the incidence of alcohol-attributable conditions. The ICUR value indicated that the programme is likely to be cost-effective from an abridged societal perspective. The intervention is projected to generate a gain of ₹8.21 (US$1.03) trillion, equivalent to per year gain of 0.59% of GDP, based on the abridged societal perspective. The deterministic sensitivity analysis indicated that reductions in diagnostic accuracy of the screening method, prevalence of AUD and treatment coverage had an inverse impact on the ICURs and could impact efficiency of the programme.

Conclusion

There is good health and economic evidence to support the integration of alcohol use disorder screening and management within routine primary care. It would be essential to deploy measures for effectiveness of the screening tool and continuity of care to enhance efficiency of the programme.

Stop calling it self‐medication: Tobacco smoking is not medicine

Jentien M. Vermeulen, Jorien L. Treur, Robyn E. Wootton, Gemma Taylor — Mon, 11 May 2026 17:03:29 -0700

Addiction, EarlyView.

Commentary on German et al.: Qualitative inquiry reduces lags in scientific discovery‐to‐practice by recognizing the living expertise of people who use drugs

Megan K. Reed — Mon, 11 May 2026 16:59:43 -0700

Addiction, EarlyView.

Early insights from a national scheme providing vaping devices for smoking cessation: A preliminary evaluation to inform future return‐on‐investment modelling in England

Esther Moore, Duncan Gillespie, Erikas Simonavičius, Leonie Brose — Sun, 10 May 2026 00:00:00 -0700

Abstract

Background and aims

Swap to Stop is a government scheme to promote smoking cessation. Local authorities in England were given e-cigarette (vape) starter kits to provide alongside behavioural support in a wide range of settings. This study evaluated (i) scheme uptake by region of England, (ii) proposed delivery settings and the type and length of support, (iii) proposed targeting of priority populations and (iv) product-cost per 4-week quit.

Design, setting and participants

From October 2023 to October 2024, local authorities submitted 218 expressions of interest (EOIs) to participate in Swap to Stop. We analysed a sample of 115 (53%) EOIs and associated cost information provided by the Department of Health and Social Care. NHS Quarterly Returns data (April 2024–September 2024) provided 4-week quit rates.

Measurements

Outcomes were the number of kits requested per adult who smokes in each region of England, the proposed delivery settings and the type and length of support and proposed targeting of priority populations categorised as ‘specific’ (exclusive to certain populations) or ‘targeted’ (accessible to all but targeting particular groups). Product-cost per 4-week quit was estimated from the 4-week quit rates and product cost.

Findings

Regional uptake varied, from 39 kits per 100 people who smoke in the Southwest to 5 per 100 in the Midlands. Most EOIs (75.7%) proposed supplying kits via existing local government funded stop smoking services, followed by physical health care settings (37.4%). A proposed duration of supply of 4 weeks was the most common (48.7%). Thirty-two percent of the EOIs described specific services, including services exclusively for pregnant women (14.8%) and people experiencing deprivation (13.9%). Frequently targeted were socioeconomically less advantaged groups (e.g. routine/manual workers, 57.4% of EOIs) and people with mental health conditions (36.5% of EOIs). The self-reported 4-week quit rate for those who received a kit was 34.3% and the average kit cost was £38.78 (the maximum cost was £40), giving an estimated product-cost per 4-week quit of £113.17, not including additional costs incurred by service providers.

Conclusions

Swap to Stop in England, a government scheme to promote smoking cessation through provision of free e-cigarette starter kits, demonstrated variation in both uptake and the types of services offering free vapes, yet the early quit rates, and consequently the product-cost per quit, were comparable to those observed in similar smoking cessation schemes. There is potential for further targeting of priority populations with increased investment to ensure people have the best chance of quitting.

Considering alcohol and other drug screening, brief intervention and referral to treatment in two safety‐sensitive industries in Australia: An exploratory qualitative study

Kirrilly Thompson, Tina Hart, Jacqueline Bowden — Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Workplaces offer a practical setting for alcohol and other drug interventions, especially in industries where impairment introduces substantial risk. Screening, brief intervention and referral to treatment has demonstrated effectiveness in health care settings and shows promise in workplace settings. However, low participation and high attrition in previous workplace studies indicate a need for deeper understanding of feasibility and acceptability. This exploratory qualitative study aimed to identify likely determinants for implementing alcohol and other drug screening, brief intervention and referral to treatment in two safety-sensitive industries in Australia.

Methods

Qualitative research design based on semi-structured online interviews, focussed on the construction and manufacturing industries. Participants included 23 professionals working in health and safety roles representing 21 organisations located across six Australian jurisdictions. Interview transcripts were coded against the five domains of the updated Consolidated Framework for Implementation Research.

Findings

Sixteen determinants were identified that were expected to act as barriers (n = 10) or enablers (n = 5) or have bidirectional impacts (n = 1) on the implementation of screening, brief intervention and referral to treatment in construction and manufacturing. Enabling factors included freely available tools, flexible delivery methods and delivery by trusted, external, peer-based organisations. Pervasive barriers included workers' mistrust of management, concerns about confidentiality and fear of consequences for disclosing substance use.

Conclusions

Successful workplace implementation of screening, brief intervention and referral to treatment appears to depend on organisational cultures where workers trust management, are assured of confidentiality and are not afraid of retribution for disclosure.

Historical trends in self‐reported US heroin initiation

Jonathan P. Caulkins, Bishu Giri — Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Illegal opioids create challenges for public health and safety. There is imperfect understanding of when use of illegally manufactured opioids increased. This paper examined data on self-reported year of first heroin use in the United States.

Design

Secondary analysis of general population survey data.

Setting

United States.

Participants

1 708 720 across 38 surveys from 1979 to 2023.

Measurements

The U.S. National Survey on Drug Use and Health and its predecessors ask respondents about their year of first use for various substances. In any single survey, few report initiating heroin in a specific year, but combining multiple surveys improves precision, enabling the plotting of time trends. Those who initiate can be broken down by age and by whether they report having misused pain relievers before they first used heroin.

Findings

Self-reported heroin initiation appears to have been rare before the late 1960s, although data for those years are sparse. It rose sharply to a peak in 1972, fell by almost half, and remained stable from 1978 to 1994. It rose by about 75% in the late 1990s and a further 85% by the early 2010s. The proportion reporting misuse of prescription opioids before first using heroin increased from about one-third before 1990 to one-half by 2000 and 80% by 2010. The proportion who were over age 40 at the time of first heroin use increased from nearly 0 before 1990 to 10% in 2012 and about 40% in 2020–2021.

Conclusions

In the United States, heroin initiation that is self-reported to have occurred after 2000 differs in magnitude and character from that from the late 1970s through mid-1990s. Changes began before dates commonly associated with restrictions on opioid prescribing. This appears consistent with a view that “trading down” from prescription opioid misuse to consumption of illegally manufactured opioids did not only occur after implementation of policies to reduce opioid prescribing.

Trends in fentanyl‐containing drug samples seized by law enforcement agencies across Canada

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Canada's drug toxicity crisis has been largely attributed to a volatile fentanyl-dominated unregulated drug supply with increasing reports of fentanyl detected in combination with benzodiazepines, stimulants and xylazine. Although rates of opioid-related harms vary significantly by region, it remains unknown how the composition of the unregulated drug supply differs across Canada. Therefore, we sought to describe trends in Canadian fentanyl-containing drug seizures nationally and compare trends by province/territory.

Design

Repeated cross-sectional analysis between February 2020 and December 2024.

Setting and cases

Fentanyl-containing drug samples seized by law enforcement agencies across Canada were analyzed by Health Canada's Drug Analysis Service, with test results made publicly available.

Measurements

Counts and crude rates of fentanyl-containing drug seizures, with the population of each province/territory used to calculate rates per 100 000. We described the number of notable drug classes (e.g. benzodiazepines, stimulants, non-fentanyl opioids, etc.) and chemical substances identified within each drug seizure and used the Cochrane Armitage Test for Trend to look for significant changes over time. All analyses were conducted overall and stratified by province/territory.

Findings

We identified 71 996 fentanyl-containing drug seizures over the study period, with the quarterly number of seizures increasing by 24.4% (from 2640 in 2020 to 3284 in 2024) across Canada. This varied by province/territory, with the highest annual rates of fentanyl-containing seizures in 2024 reported in British Columbia (60.4 per 100 000) and Alberta (52.3 per 100 000). Among fentanyl types, we observed statistically significant increases (P < 0.001) in the detection of para-flurofentanyl (0.0% to 46.3%) and methylfentanyl (0.0% to 28.6%). Additionally, there was a notable rise in the annual proportion of seizures in which benzodiazepines (13.4% to 40.2%) or xylazine (1.5% to 18.9%) were detected. Approximately half of all seizures contained fentanyl in combination with at least one other drug class and over 95% contained fentanyl in combination with at least one other chemical substance.

Conclusions

Across Canada from 2020 to 2024, there has been a 24% increase in fentanyl-containing drug seizures in which multiple substances are detected, most notably benzodiazepines, xylazine and potent fentanyl analogues within a single sample.

Navigating pregnancy and addiction recovery: Patient perspectives on perinatal care interventions for women with opioid use disorder in Kentucky, USA

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

The state of Kentucky has been heavily impacted by the ongoing opioid crisis in the United States, with high overdose mortality, high prevalence of opioid use disorder (OUD), elevated maternal mortality and incidence of Neonatal Abstinence Syndrome. Evidence-based care for pregnant people with OUD remains limited in many areas of the state, and patient perspectives are urgently needed to understand the acceptability of intervention approaches, and broader perspectives on prenatal and recovery care in their communities. This study aimed to understand women's experiences with prenatal care and substance use treatment in Kentucky throughout the perinatal period.

Design

Data were drawn from a recently completed Patient-Centered Outcomes Research Institute (PCORI) funded comparative effectiveness trial known as PATHHome, whose overarching objective was to study the delivery of a pregnancy-specific educational recovery curriculum for pregnant women treated for OUD in Kentucky. PATHHome was a pragmatic, non-inferiority, cluster randomized trial testing group versus telemedicine interventions for delivering care. We conducted a qualitative study with trial completers.

Setting

PATHHome was conducted in 13 clinical sites across eastern and central Kentucky.

Participants

Eligible patient participants were: (1) between ages 18–55, (2) pregnant (between 6 and 32 weeks' gestation), (3) diagnosed with OUD, and (4) being treated with medications for opioid use disorder (MOUD). Thirty-three participants across 10 clinical sites were ultimately interviewed.

Measurements

Participants were invited to complete an in-depth qualitative interview at the time of their final 6-month postpartum follow-up visit. Interview coding was conducted using a hybrid inductive-deductive approach and consensus coding techniques were used. Coding and analysis were conducted in NVivo.

Findings

Systematic analysis of patient experiences revealed four overarching themes: Theme 1. MOUD stigma diminishes the quality of perinatal care for women with OUD, highlighting the need for expanded integration of evidence-based MOUD, prenatal and delivery care; Theme 2. Navigating siloed and inconsistent care system policies contributes to suboptimal delivery experiences and limits parenting opportunities; Theme 3. Maternal engagement in perinatal OUD interventions is enhanced by responsive and adaptable approaches that address patient beliefs, circumstances and histories; and Theme 4. A pregnancy-specific educational recovery curriculum delivered by a supportive, nonjudgmental and multidisciplinary intervention team promotes high acceptability among women on MOUD.

Conclusions

In Kentucky, USA, there appears to be a high level of acceptability for a pregnancy-specific opioid use disorder recovery education intervention among pregnant patients on medications for opioid use disorder (MOUD). Major recommendations include prioritizing the expansion of integrated prenatal and addiction care, including through the use of telehealth in communities with insufficient clinical capacity, and engaging the entire perinatal healthcare team in stigma training and foundational training on MOUD, which may reduce episodes of enacted stigma in the care setting.

Quitting trajectories of Hong Kong Chinese smokers receiving behavioral smoking cessation interventions: A post hoc analysis of eight randomized controlled trials

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Characterizing distinct quitting trajectories may inform tailored behavioral smoking cessation interventions. We identified the quitting trajectories and associated characteristics in Hong Kong Chinese smokers.

Methods

Data were from eight randomized controlled trials nested within the annual Smoking-free Community Campaign (‘Quit-to-Win’ Contest) from 2014 to 2021. The trials were two- or three-arm evaluating the effectiveness of behavioral smoking cessation interventions in 8300 adult daily smokers who were proactively recruited from communities across Hong Kong and followed-up at 1, 2, 3 and 6 months. Daily cigarette consumption was collected at baseline and follow-ups for identifying quitting trajectories by group-based trajectory modeling based on relative changes in cigarette consumption (vs. baseline) over four follow-up assessment points. Multinomial logistic regressions were used to yield relative risk ratios (RRRs) for the trajectories by baseline smoking-related characteristics, adjusting for sex, age, economic status and education attainment.

Results

Four quitting trajectories were identified, including quitters (4.6%), relapsers (6.8%), reducers (54.8%) and persistent smokers (33.8%). Compared with persistent smokers, smokers in the other 3 trajectories were associated with having previous quit attempts, higher intention to quit and perceived higher importance and confidence in quitting (all P < 0.05). Quitters [adjusted RRR (aRRR) = 0.59, 95% confidence interval (CI) = 0.62–1.00] and relapsers (aRRR = 0.75, 95% CI = 0.61–0.91) reported lower nicotine dependence vs. persistent smokers, whereas reducers showed higher nicotine dependence (aRRR = 1.39, 95% CI = 1.25–1.55) at baseline. Relapsers and reducers perceived higher difficulty of quitting (all P < 0.05). When compared with quitters, relapsers had higher intention to quit within 7 days (aRRR = 2.32, 95% CI = 1.64–3.28) and perceived higher importance (aRRR = 1.17, 95% CI = 1.09–1.25) and confidence (aRRR = 1.10, 95% CI = 1.04–1.17) in quitting, while reducers showed lower intention to quit within 7 days (aRRR = 0.59, 95% CI = 0.45–0.77) and perceived lower confidence in quitting (aRRR = 0.91, 95% CI = 0.86–0.95). Subgroup analysis of different interventions showed similar trajectory shapes and group probabilities.

Conclusions

Chinese smokers who joined behavioral smoking cessation trials in Hong Kong appear to have four quitting trajectories, each with associated characteristics, which may help predict the potential quitting trajectories and inform future interventions.

The association between gambling frequency and risk of harm: Analysis using health survey data from England and Scotland

Esther Moore, Robert Pryce, Hazel Squires, Elizabeth Goyder — Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Health economic models can be used to assess the effectiveness and cost-effectiveness of public health policies for gambling. To develop such a model, we must understand how gambling behaviour is associated with risk of experiencing gambling-related harms. This study aimed to: (1) assess the strength of association between gambling frequency and the risk of gambling-related harm and to examine how these associations differ when lottery-only players are excluded; (2) apply the study's findings in a hypothetical policy model aimed at reducing gambling frequency.

Design

Observational study using six waves of cross-sectional data from the Health Survey for England and the Scottish Health Survey.

Setting

Survey conducted in England in 2015, 2016 and 2018 and Scotland in 2015, 2016 and 2017.

Participants

The sample included 16 648 adults (aged 18 and over) who reported gambling in the past year, generally representative of the populations of England and Scotland.

Measurements

Gambling frequency was measured using 6 categories which indicated frequency in the past 12 months: (a) 2 or more times a week; (b) once a week; (c) less than once a week, more than once a month; (d) once a month; (e) every 2–3 months; (f) once or twice a year. Risk of gambling-related harm was assessed using Problem Gambling Severity Index (PGSI) score (0–27) and its four categories: no-risk (0), low-risk (1–2), moderate-risk (3–7) and high-risk (≥8). Control variables included age, sex, deprivation, social grade, presence of mental disorder and frequency of drinking alcohol.

Findings

Using multinomial logistic regression and zero-inflated negative binomial models we found that gambling at least twice weekly was associated with a statistically significantly higher PGSI score than gambling once or twice a year (incidence rate ratio = 3.528, 95% confidence interval = 2.040–6.103, P value < 0.001). Reducing gambling to guideline levels for people gambling at least twice weekly moved 10% of the sub-sample from higher PGSI categories (low, medium and high risk) to the no-risk category and shifted the distribution of PGSI scores down.

Conclusions

There appears to be a statistically significant association between gambling frequency and risk of gambling-related harm. Data derived from this and similar analyses can be used to model gambling policies which impact gambling frequency.

The feasibility of integrating remote breath alcohol monitoring into ecological momentary assessment of intimate partner violence among young adults with a history of heavy drinking and aggression

Fri, 08 May 2026 08:06:35 -0700

Abstract

Aims

We examined the feasibility and acceptability of pairing portable breathalyzers to assess field alcohol use with mobile ecological momentary assessment (EMA) to assess intimate partner violence (IPV; psychological, cyber, physical and sexual aggression) perpetration and victimization among undergraduates who drink heavily and were recently aggressive.

Design, setting and participants

We assessed EMA/breathalyzer completion rates, drinking captured via breathalyzer versus self-report, number of IPV events captured, procedural acceptability and reactivity to assessment. Sex differences were examined. Undergraduates aged 18–25 (n = 103; M age = 21 years, SD = 2.0; 52% women; 80.6% heterosexual; 64.1% white; 93.2% non-Hispanic) recruited from a large Mid-Atlantic university in the United States completed a baseline survey then a 30-day EMA wherein they were prompted to complete one morning and three evening surveys (7 PM, 9 PM, 11 PM) daily. After each evening survey, participants were prompted to submit a breath alcohol content (BrAC) sample to a breathalyzer linked to surveys. Participants could self-initiate surveys after drinking or IPV outside of assessment periods. Afterward, participants completed an exit survey.

Measurements

Outcome variables were self-reported alcohol use and IPV assessed via EMA surveys, and BrAC assessed via breathalyzer. Self-reported procedural acceptability was assessed in the exit survey. Reactivity to assessment was assessed by analyzing daily trends in IPV and drinking by sex using generalized linear mixed effects models.

Findings

Participants completed 80% of surveys and responded to 91% of breathalyzer prompts. BrAC was captured in 89.4% of self-reported drinking events, 91.4% of self-reported non-drinking events and 95.8% of IPV events, with greater responsiveness to breathalyzer prompts as the evening progressed despite increasing intoxication. More IPV events were captured during evening and event triggered (358 combined total events) than morning surveys (245 events). Results were comparable across women and men. Each additional study day was associated with modest declines in odds of experiencing any IPV [odds ratio (OR) = 0.95, 95% confidence interval (CI) = 0.94–0.97, P < 0.001], IPV perpetration (OR = 0.94, 95% CI = 0.92–0.96, P < 0.001), IPV victimization (OR = 0.97, 95% CI = 0.96–0.99, P = 0.004), any drinking (OR = 0.99, 95% CI = 0.98–1.00, P = 0.01) and positive BrAC readings (OR = 0.99, 95% CI = 0.98–1.00, P = 0.052), suggesting minimal reactivity to assessment. Participants reported high overall satisfaction with study components.

Conclusions

Pairing ecological momentary assessment with portable breathalyzers to capture data on drinking and intimate partner violence across 30 days among US undergraduates who were previously aggressive and who drink heavily appears to be both feasible and acceptable.

Exploring the intersection of heavy alcohol use and masculine norms as risk factors for male‐to‐female intimate partner violence: Evidence from an Australian national survey

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Endorsement of traditional masculine norms and male alcohol use are identified risk factors for male-to-female intimate partner violence (MFIPV) perpetration, yet their interaction remains unexplored in Australia. This study aimed to estimate the associations between heavy male alcohol use, endorsement of traditional masculine norms and MFIPV perpetration, and test their interaction among Australian men.

Design and setting

Cross-sectional analysis of nationally representative data from Wave 1 (2013–2014) of the Australian Longitudinal Study on Male Health (Ten to Men).

Participants

Participants were 12 284 men who were Australian citizens or permanent residents aged 18 years or older who identified as heterosexual and answered any of the MFIPV items.

Measurements

The primary outcome was lifetime MFIPV perpetration assessed through three items on frightening, physically harming or forcing sex on a partner. Predictors included past-year heavy episodic drinking (HED) and endorsement of masculine norms. Sociodemographics, other drug use, depression, anxiety and sexual performance problems were included as covariates. Multivariable logistic regression models with 95% confidence intervals (CI) were used to examine associations between sociodemographics, specific masculine norms, HED, total masculinity scores and perpetrating MFIPV. An interaction between HED and masculinity on MFIPV was also tested.

Findings

Of the 12 284 men (M_age = 38.3 years), 2947 (23.8%, 95% CI = 22.7–25.0) reported lifetime perpetration of MFIPV, with men aged 30–49 years reporting the highest perpetration rate (26.8%, 95% CI = 24.5–29.1). Higher mean scores on playboy, risk-taking, self-reliance, power over women and violence norms were associated with increased odds of reporting MFIPV perpetration, whereas greater scores on emotional control, primacy of work and heterosexual presentation norms appeared protective. Past-year HED [odds ratio (OR) = 1.24, 95% CI = 1.05–1.48] and greater total masculinity scores (OR = 1.03, 95% CI = 1.01–1.04) were both independently associated with statistically significantly higher odds of reporting lifetime MFIPV perpetration. A statistically significant interaction effect revealed higher total masculinity scores were associated with increased odds of MFIPV perpetration among men with past-year HED, after adjusting for sociodemographic characteristics and covariates (OR = 1.03, 95% CI = 1.00–1.06, P = 0.035), but not among men who did not engage in HED.

Conclusions

Among Australian men, heavy episodic drinking appears to modify the association between traditional norms of masculinity and reporting male-to-female intimate partner violence, with stronger endorsement of traditional masculine norms associated with higher odds of perpetration among men reporting past-year heavy episodic drinking.

Decline of phosphatidylethanol (B‐PEth) during abstinence in patients with alcohol use disorder undergoing withdrawal treatment, and the correlation of B‐PEth with self‐reported alcohol intake

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aim

Accurately estimating alcohol consumption is crucial for clinical decision-making and monitoring treatment outcomes. Phosphatidylethanol in blood (B-PEth), a direct alcohol biomarker, is currently the most reliable indicator of alcohol intake, with a detection window of several weeks; however, the factors influencing the decline of B-PEth levels remain largely unknown. This study aimed to investigate the decline of B-PEth levels during abstinence in patients with alcohol use disorder (AUD) undergoing withdrawal treatment.

Method

A total of 100 patients were recruited in withdrawal treatment and followed during three to four weeks of abstinence. Blood samples were collected at baseline and weekly during abstinence to measure B-PEth levels of two homologues (16:0/18:1 and 16:0/18:2). Self-reported alcohol consumption was documented using the Timeline Followback (TLFB) method for 30 days before abstinence and throughout the study period.

Results

B-PEth elimination followed first-order kinetics. The mean half-life was 7.24 days [95% confidence interval (CI) = 6.98–7.53] for 16:0/18:1 and 4.55 days (95% CI = 4.44–4.67) for 16:0/18:2. The rate of decline varied by week, with a longer half-life observed in week three compared with week one. No statistically significant sex differences were detected. The strongest correlation between B-PEth levels and self-reported alcohol consumption was found for data from two weeks prior to abstinence.

Conclusion

Elimination of phosphatidylethanol in blood (B-Peth) follows first-order kinetics, with homologue 16:0/18:1 exhibiting a longer half-life than 16:0/18:2. The rate of decline is influenced by the week of alcohol abstinence and B-PEth levels are detectable even in the fourth week of abstinence. The strongest correlation between B-PEth and self-reported alcohol consumption is at two weeks prior to abstinence.

Retention in opioid agonist treatment during pregnancy and variations according to treatment and maternal characteristics

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

To measure the proportion of women in New South Wales, Australia, retained in opioid agonist treatment (OAT) for opioid dependence (OD) during pregnancy and examine how this varies according to treatment and maternal characteristics.

Design

Retrospective cohort study using linked population-based data, including OAT records, perinatal, hospital admissions, mental health outpatient services and criminal justice data.

Setting

New South Wales, Australia, January 2004–December 2021.

Participants

Pregnancies resulting in childbirth among women receiving OAT during pregnancy. The cohort included 4472 pregnancies among 2821 women receiving OAT during pregnancy.

Measurements

We defined retention as continuous receipt of OAT from the date of OAT initiation during pregnancy or date of conception (whichever came last) until childbirth. We calculated the proportion of women retained in treatment and 95% confidence intervals (CI) overall, by timing of initiation (pre-conception, first, second and third trimester) and medication type (methadone, buprenorphine) at initiation. We used logistic regression to assess retention variation according to maternal socio-demographic and clinical factors, including morbidities commonly co-occurring with OD, stratified by timing of initiation. Data on dosing, other substance use and psychopharmacological medications were unavailable.

Findings

OAT was initiated pre-conception in 74.8% (3346) of pregnancies, during the first trimester in 11.1% (n = 497), second trimester in 8.8% (n = 394) and third trimester in 5.3% (n = 237). Overall, women were retained in OAT for 84.3% (3771) of all pregnancies. Retention was 87.4% (95% CI = 86.3–88.6) with pre-conception initiation; 65.8% (95% CI = 61.6–70.0) in the first trimester; 80.5% (95% CI = 76.5–84.4) second trimester; and 85.2% (95% CI = 80.8–89.7) third trimester. Retention was 72.4% (95% CI = 69.5–75.3) with buprenorphine and 87.7% (95% CI = 86.6–88.9) with methadone. Pregnancies delivered during 2019–2021 were less likely to be retained in treatment compared with those delivered during 2004–2006, regardless of the timing of initiation [pre-conception initiation odds ratio (OR) = 0.49, 95% CI = 0.30–0.79; first trimester initiation OR = 0.29, 95% CI = 0.08–1.07; second/third trimester initiation OR = 0.29, 95% CI = 0.10–0.91). Among women who initiated OAT pre-conception, retention was lower among those whose first antenatal visit occurred after 20 gestational weeks (OR = 0.68, 95% CI = 0.53–0.86), those in their first (OR = 0.72, 95% CI = 0.54–0.97) or second pregnancy (OR = 0.73, 95% CI = 0.56–0.96) and those who initiated on buprenorphine (OR = 0.31, 95% CI = 0.24–0.40) or in a custodial setting (OR = 0.66, 95% CI = 0.44–1.01).

Conclusions

In New South Wales, Australia, from 2004 to 2021, over 84% of women receiving opioid agonist treatment during pregnancy were retained in treatment until childbirth; however, lower retention in later study years and among women initiating buprenorphine, coupled with recent guidelines recommending buprenorphine as first-line therapy during pregnancy, highlights the need for ongoing monitoring and targeted support to improve retention among women who are at higher risk of discontinuation.

Associations between the national ‘Swap to Stop’ programme offering free vapes for smoking cessation and quit attempts in England: Results from a population‐based survey

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Vapes are effective for smoking cessation. The UK Government launched the Swap to Stop initiative in England in December 2023, aiming to encourage people to quit smoking by providing free vape starter kits alongside behavioural support. This study aimed to assess the association between the introduction of Swap to Stop and the proportion of people in England who tried to quit smoking using vapes in the past year.

Design

Data came from the Smoking Toolkit Study, a monthly cross-sectional population-based survey. The primary analysis used an interrupted time-series approach based on Autoregressive Integrated Moving Average (ARIMA) regression models.

Setting

Telephone interviews with people residing in private households in England between December 2021 and December 2024.

Participants

People aged ≥16 years who smoked in the past year.

Measurements

The outcome was vape use during past-year quit attempts. The intervention effect was included as a step change in December 2023 to indicate the start of the Swap to Stop programme. The model also included a dummy variable to adjust for above-inflation tobacco tax increases.

Findings

The primary analysis indicated that the introduction of Swap to Stop in December 2023 was associated with a 1.5 absolute percentage point increase (adjusted B = 0.015, 95% confidence interval = 0.005–0.025) in the proportion of people in England using vapes in past-year quit attempts that persisted to December 2024.

Conclusions

The introduction of Swap to Stop (which provides free vape starter kits with behavioural support to quit smoking) in England appears to be associated with a statistically significant increase in quit attempts using vapes.

The Polysubstance Assessment Tool: Reliability, acceptability and feasibility of a novel measure of polysubstance use

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

There are currently no brief quantitative assessments that capture the drug patterns of people who engage in use of more than one drug on the same day or simultaneously. The current study examined the retest reliability, acceptability and feasibility of a new quantitative assessment to measure polysubstance use.

Design

A tool for assessing simultaneous and same-day polysubstance behaviors, the polysubstance assessment tool (PAT) was developed in interviewer-administered and electronic self-administered formats. Participants were allocated 1:1 to receive either version of the PAT and returned one to three days later to repeat the assessment.

Setting

New York City, New York, USA.

Participants

Adults (18 + years, n = 115) who reported use of more than one drug per day in the last 30 days.

Measurements

Test–retest reliability estimates for dichotomous items were assessed using Cohen's kappa, Gwet's Agreement Coefficient 1 (AC1) and percent agreement. Continuous items were assessed with two-way mixed effects intraclass correlations. Bivariate analyses examined acceptability using nine Likert-type survey questions. Feasibility was examined via time to completion.

Findings

Overall reliability was moderate to excellent [Gwet's AC1 range 0.70–0.96; intraclass correlation (ICC) range 0.62–0.88]. Reliability was higher for simultaneous polysubstance use (Gwet's AC1 = 0.90) as compared with same-day (Gwet's AC1 = 0.70). Acceptability was high, with no statistically significant difference between the self- and interviewer-administered versions of the tool. Median time to completion was 7 minutes, and was statistically significantly lower for the self-administered tool (median = 5 minutes) compared with the interviewer-administered version (median = 8 minutes) (P < 0.001).

Conclusions

A new polysubstance assessment tool appears to have good reliability and can be considered by researchers seeking a quantitative measure of polysubstance use behaviors given its simplicity, high acceptability and quick completion time.

Commentary on Morris et al.: Shifting consumption from unhealthy to healthy commodities

Daniel Araya‐Ríos — Fri, 08 May 2026 08:06:35 -0700

Addiction, Volume 121, Issue 6, Page 1408-1409, June 2026.

Commentary on Buss et al.: State endorsement as a driver of vape‐assisted smoking cessation: Interpreting early evidence from Swap to Stop

Nadia Minian — Fri, 08 May 2026 08:06:35 -0700

Addiction, Volume 121, Issue 6, Page 1566-1567, June 2026.

New Books

Fri, 08 May 2026 08:06:35 -0700

Addiction, Volume 121, Issue 6, Page 1622-1624, June 2026.

Screening for addiction in the dental office: The bottom line

Carrigan L. Parish, Lisa E. Simon — Fri, 08 May 2026 08:06:35 -0700

Addiction, Volume 121, Issue 6, Page 1340-1342, June 2026.

Issue Information

Fri, 08 May 2026 08:06:35 -0700

No abstract is available for this article.

Issue Information

Fri, 08 May 2026 08:06:35 -0700

No abstract is available for this article.

Rare but relevant: Ibogaine and cardiovascular complications—prolonged QT interval and ventricular arrhythmias

Tibor Markus Brunt — Fri, 08 May 2026 08:06:35 -0700

Abstract

Revived interest in psychedelic-assisted therapies has also renewed focus on ibogaine, a psychoactive alkaloid, for its notable anti-addictive potential. Evidence from observational, open-label, and limited randomized placebo-controlled trials indicates that ibogaine and its metabolite noribogaine reduce craving and withdrawal symptoms in opioid and cocaine-dependent individuals, primarily through multiple pharmacological mechanisms; however, ibogaine presents a rare yet clinically significant cardiotoxic risk: QTc prolongation and potentially fatal ventricular arrhythmias such as Torsades des Pointes. Case reports demonstrate that these events occur with therapeutic doses of ibogaine and in individuals without pre-existing cardiac conditions. A large interindividual variability in CYP2D6 metabolism of ibogaine was shown and might contribute to higher cardiovascular risk in certain individuals. Recent efforts to improve safety of ibogaine include different dosing strategies, cardiovascular monitoring and the development of ibogaine analogues, which retain anti-addictive efficacy while lacking cardiotoxicity in preclinical models. Future ibogaine-assisted treatment should be conducted exclusively under controlled medical supervision, with CYP2D6 genotyping and rigorous monitoring of cardiovascular functioning. Future clinical trials should prioritize evaluation of safer analogues and personalized dosing strategies to optimize the benefit–risk profile of this emerging therapy.

A systematic review and meta‐analysis of self‐reported exposure to cannabis advertising and its association with cannabis use and intentions

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and Aims

Global changes in cannabis legislation have raised concerns about the potential impact of cannabis advertising on cannabis use and intentions to use. This systematic review and meta-analysis evaluated the relationship between self-reported exposure to cannabis advertising across various media platforms and self-reported cannabis use and use intentions.

Design

Systematic review and meta-analysis of eligible quantitative studies using random-effects models.

Setting

All included studies were conducted in the United States or Canada.

Participants

Participants ranged in age from 11 to 65 + years across 21 included studies.

Measurements

Studies measured self-reported exposure to cannabis-related advertising and either cannabis use or intentions to use cannabis. Three types of exposure were examined: [1] general cannabis advertising (a composite measure including billboards, storefront/sidewalk, magazines, social media, and other types of advertising avenues), [2] internet/social media advertising, and [3] storefront/sidewalk advertising.

Findings

A total of 2588 records were identified through database searches (PubMed, Scopus, and PsycINFO; January 2024). After title and abstract screening, 45 underwent full text review; of these, 21 studies met inclusion criteria. Most were cross-sectional (86%, n = 18), and three were longitudinal. Ten cross-sectional studies were eligible for meta-analysis, which found a statistically significant association between cannabis advertising exposure and cannabis use (adjusted odds ratio [aOR] = 1.77, 95% confidence interval [CI] [1.32, 2.30]). Statistically significant heterogeneity was found (Q [11] = 22.73, P < 0.05, I² = 42.3%) and therefore, based on methodological comparability, three additional meta-analyses were conducted by exposure type. General cannabis advertising (3 studies) exposure was statistically significantly associated with cannabis use (aOR = 1.67, 95% CI [1.27, 2.21]); internet/social media advertising (5 studies) also showed a statistically significant association (aOR = 3.38, 95% CI [1.07, 10.66]); exposure to storefront/sidewalk advertising (3 studies) was not statistically significantly associated with cannabis use (aOR = 1.25, 95% CI [0.95, 1.66]). Across studies, methodological quality was mostly good (48%) or satisfactory (43%), with 10% rated as unsatisfactory.

Conclusion

There appears to be a generally positive association between exposure to cannabis advertising and cannabis use, with a consistent positive relationship observed between advertising exposure and intentions to use.

Understanding the relationship of social anxiety with alcohol use and alcohol‐related problems in young people: A meta‐analysis

Anton J. Fichtenmaier, Amanda M. George — Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Social anxiety is associated with disparate alcohol-related outcomes among young people. This meta-analysis synthesised the literature to determine what factors (e.g. impulsivity) may account for variance in these outcomes.

Methods

Empirical studies reporting the correlation of social anxiety with alcohol use and/or alcohol-related problems (ARPs) among young people (aged 13–29 years) were identified through a systematic literature search. Five random-effects meta-analyses were performed for ARPs, problematic alcohol use, frequency, quantity and quantity by frequency index measures of alcohol use. Seventy studies were included with 233 effect sizes extracted. The average age was 20 years (n = 38 517; 66.2% female).

Results

Social anxiety was negatively associated with index alcohol use [number of studies (k) = 28, r = −0.05, 95% confidence interval (CI) = −0.08 to −0.03, t = −4.04, P < 0.001] but statistically non-significant with quantity (k = 21, r = 0.00, 95% CI = −0.04 to 0.05, t = 0.18, P = 0.86) or frequency (k = 18, r = −0.01, 95% CI = −0.06 to 0.05, t = −0.29, P = 0.78) of alcohol use. Social anxiety was statistically significantly positively associated with ARPs (k = 45, r = 0.13, 95% CI = 0.10–0.16, t = 9.93, P < 0.001) and problematic alcohol use (k = 23, r = 0.06, 95% CI = 0.01–0.11, t = 2.68, P = 0.01). Impulsivity was a statistically significant moderator, such that, as the correlation of impulsivity with social anxiety increased, the association of social anxiety with index alcohol use positively increased. Subgroup analyses for ARPs measure used were also statistically significant.

Conclusion

Young people with elevated social anxiety appear to drink less alcohol than their peers, but report more problematic alcohol use and alcohol-related problems. Impulsivity may clarify unexpected patterns of lower alcohol consumption, although conclusions remain tentative due to methodological constraints.

Tissue‐retained needles in people who inject drugs: A systematic review of case reports and series on clinical presentations, complications and management

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Tissue-retained needles from intravenous drug use can cause rare but severe complications, ranging from local to systemic infections to needle embolization. Due to the limited evidence and the lack of epidemiological studies on the issue, we systematically reviewed the literature focusing on case reports and case series on the clinical presentations, diagnostic approaches, and management of tissue-retained needle fragments.

Methods

A systematic review of English-language case reports and case series was conducted (PROSPERO ID: CRD42024517020) on 15 November 2024, using PubMed and Scopus. Two authors performed the search independently and in duplicate following the PRISMA flow diagram. Case reports were included when the retained needles among people who inject drugs were confirmed by imaging, surgery or autopsy. Data on clinical characteristics, presentation, complications and outcomes were extracted by two reviewers and summarized descriptively.

Results

From 1479 citations, we included 46 publications reporting 52 cases [47 (90%) patients and 5 (9.6%) autopsy cases]. Patients were mostly young adults with a median age of 35.0 (range: 22–55) years and predominantly male [n = 37/52 (71%)]. No deaths were reported among the patients presenting with needle fragments; in the autopsy cases, the needles were incidental findings and not the cause of death. Although injection sites were not systematically imaged in all cases, nearly one third [n = 15/52 (29%)] of cases involved multiple retained needles. Needles migrated via circulation were most often found in the heart [n = 23/52 (44%)] or the lungs [n = 13/52 (25%)]. One fifth [10/47 (21%)] of the patients received antibiotics without needle retrieval, and in 18/47 patients (38%) the needle was surgically removed.

Conclusions

Retained needle fragments among people who inject drugs are found in a range of anatomical sites, are often multiple, are not associated with fatal outcomes and are often incidental findings in autopsies. Management varies substantially as some patients receive antibiotics alone while some have needles removed surgically.

Bidirectional genetic and phenotypic links between smoking and striatal iron content involving dopaminergic and inflammatory pathways

Olga Trofimova, Ilaria Iuliani, Sven Bergmann — Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Tobacco smoking is a major risk factor for cardiovascular and lung diseases. A better understanding of its neurobiological underpinnings will benefit the prevention of smoking-related illnesses and mortality. Previous studies link smoking to increased iron concentration in the striatum, a central component of the brain's reward system, and to reduced cognitive performance. This study aimed to investigate whether smoking and striatal iron share common biological pathways and to assess potential causal relationships between the two.

Methods

Using data from the UK Biobank, we investigated phenotypic and genetic correlations, and causal relationships between smoking initiation and magnetic resonance imaging (MRI)-derived markers of iron content (T2* and quantitative susceptibility mapping) in the bilateral putamen, caudate and accumbens nuclei.

Results

We found positive correlations between smoking and striatal iron (β ∈ [0.03, 0.40], P < 0.001), particularly when comparing current smokers with never smokers. Striatal iron was positively associated with pack-years (β ∈ [0.11, 0.13], P < 0.001) and inversely related to years since smoking cessation (β ∈ [0.06, 0.10], P < 0.001), suggesting iron levels may decrease after quitting. Genetic analysis confirmed phenotypic correlations, with shared genetic associations (P < 2.73 × 10⁻⁶, or 0.01 for candidate genes) in genes related to dopaminergic, glutamatergic and synaptic systems (DRD2, PPP1R1B, NCAM1, DLX5, GGACT, NAT16, PLEKHM1). Causality analysis revealed a relationship from smoking to striatal iron via genes involved in synaptogenesis and plasticity (BAI3, SEMA6D, TENM2), with evidence of reverse causality from iron to smoking through inflammatory and immune system-related genes (ING5, NLRP7).

Conclusions

There appear to be links between smoking and striatal iron with complex causal mechanisms involving synaptic transmission and inflammatory circuits. Striatal iron content could serve as a biomarker for smoking-related neurobiological changes and a potential target for interventions aimed at mitigating cognitive decline related to striatal iron accumulation.

Gender differences in the impact of psychological distress on methamphetamine use disorder outcomes and treatment effect

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Methamphetamine use disorder (MUD) is a major public health concern, often complicated by co-occurring psychological distress (PD). Evidence suggests gender differences in both the prevalence of PD and its impact on treatment outcomes. This study examined impacts of PD on MUD treatment outcomes, focusing on gender differences.

Design

Secondary analysis of pooled data from five randomized controlled trials of pharmacotherapy for MUD available on the NIDA DataShare site (accessed 19 October 2024). Individual participant data meta-analysis methods were used, adjusting for sociodemographic factors and accounting for heterogeneity across trials. Regression analyses were conducted for total sample and stratified by gender.

Setting

Treatment facilities in the US.

Participants

Adults seeking MUD treatment (n = 866).

Measurements

PD was assessed using the Addiction Severity Index psychiatric domain (≥24.6 cutoff). Outcomes included reductions in methamphetamine use and positive urine tests for methamphetamine and other drugs.

Findings

PD was found in 39.9% of participants. PD was more common among women than men [odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.15–2.12], and among individuals who were younger (ages 35–45 vs. <35: OR = 0.72, 95% CI = 0.61–0.85; >45 vs. < 35: OR = 0.62, 95% CI = 0.44–0.88), had lower education (OR = 1.38, 95% CI = 1.16–1.65), chronic medical conditions (OR = 1.60, 95% CI = 1.16–2.20), history of injection drug use (OR = 1.47, 95% CI = 1.13–1.91) and prior treatment for alcohol use disorder (OR = 2.52, 95% CI = 1.64–3.84). PD was associated with lower odds of reduced use [adjusted OR (aOR) = 0.74, 95% CI = 0.66–0.82] and higher odds of positive methamphetamine urine tests (aOR = 1.27, 95% CI = 1.08–1.49). Stratified analyses revealed a stronger association among women between PD and lower odds of reduced use (aOR = 0.41, 95% CI = 0.23–0.75) and higher odds of positive urine tests for methamphetamine (aOR = 2.18, 95% CI = 1.25–3.81) and other drugs (aOR = 3.16, 95% CI = 1.53–6.47), whereas men showed no statistically significant impact of PD on treatment outcomes. A statistically significant interaction between treatment, gender and PD (P < 0.001) indicated that women without PD benefited more from treatment than those with PD, a pattern not mirrored in men.

Conclusion

Psychological distress appears to negatively impact outcomes for MUD and the effects of MUD treatment, particularly among women. Integrated psychological interventions, tailored by gender, may enhance treatment efficacy for individuals with co-occurring MUD and psychological distress.

Hippocampal subfield differences in people with and without recreational ketamine use: Insights from multi‐modal neuroimaging

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Recreational ketamine use has increased globally and is associated with psychiatric and cognitive concerns. The hippocampus in preclinical models shows damage and working-memory disruption with repeated dosing. However, whether specific hippocampal subregions may differ in people with chronic ketamine use remains unclear. In Taiwan, ketamine is predominantly consumed by smoking ketamine mixed with tobacco, producing smoking-related behavioral profiles like non-ketamine tobacco use participants (TUs). We therefore examined individuals with urine-confirmed ketamine as the only detected substance who reported predominantly smoking-administered recreational use (KUs) and used TUs as controls. This study aimed to: (1) characterize ketamine-use patterns and psychiatric symptoms; (2) compare working-memory and affective-behavioral measures between KUs and TUs; (3) quantify group differences in hippocampal subregion volumes; and (4) assess group differences in functional connectivity (FC) of identified subregions and relationships with neurotransmitter receptor distributions.

Design

Cross-sectional case-control study with cognitive testing and neuroimaging.

Setting

Community-based recruitment in Taiwan.

Participants

58 KUs (44 males; mean age = 21.00 ± 4.57) and 73 TUs (52 males; mean age = 24.34 ± 5.86).

Measurements

Ketamine-use patterns (Addiction Severity Index), psychiatric symptoms [Symptom Checklist-90-Revised (SCL-90-R)], working-memory (N-back), affective-behavioral measures [Barratt Impulsiveness Scale (BIS-11), Buss and Perry Aggression Questionnaire (BPAQ), Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSRQ)], hippocampal subfield volumes (FreeSurfer) and functional connectivity (FC) of identified subregions (seed-based analysis). Spatial correspondence with N-methyl-D-aspartate (NMDA) receptor density was evaluated using JuSpace.

Findings

Heavier ketamine use was associated with greater psychological distress [Global Severity Index (GSI) r = 0.343, P = 0.011], particularly anxiety (r = 0.457, P < 0.001) and hostility (r = 0.442, P < 0.001). Although self-reported impulsivity, aggression and reward/punishment sensitivity did not differ between groups, KUs showed reduced accuracy under higher working-memory load [2-back: F(1, 124) = 4.16, P = 0.04, partial η ² = 0.03; 1-back: F(1, 124) = 8.10, P = 0.005, η2 = 0.06]. KUs displayed reduced left hippocampal volume [F(1, 119) = 4.23, P = 0.04, η2 = 0.03], most marked in the hippocampal-amygdaloid-transition-area [HATA; F(1, 119) = 10.52, P = 0.002, η2 = 0.08]. KUs also showed increased FC between left HATA and frontal, cingulate, temporal, subcortical, insular and cerebellar regions (P < 0.05, AlphaSim corrected), which correlated with NMDA-receptor distributions (z = 0.30, P = 0.005, false discovery rate corrected).

Conclusions

Recreational smoking-administered ketamine use appears to be associated with dose-dependent psychiatric symptoms, load-dependent working memory impairment, selective hippocampal subregion volumetric differences and altered network connectivity aligned with N-methyl-D-aspartate- (NMDA) receptor distribution.

Adolescent cannabis use and psychological distress from 2013 to 2023: A population‐based study in Ontario, Canada

Fri, 08 May 2026 08:06:35 -0700

Abstract

Background and aims

Epidemiologic research suggests that adolescent cannabis use is associated with psychological distress (i.e. depression and anxiety symptoms); however, most studies have relied on 20th-century data, when cannabis was significantly less potent than today. This study aimed to estimate the association between adolescent cannabis use and psychological distress using contemporary population-based data and examine the roles of time [as a proxy for increasing Δ9-tetrahydrocannabinol (THC) potency], sex and age of initiation.

Design

Representative cross-sectional survey conducted biennially from 2013 to 2023.

Setting

Ontario, Canada.

Participants

35 007 adolescents in grades 7 to 12.

Measurements

Past-year cannabis use was categorized as Never, 1–2 times, 3–9 times, 10–39 times or 40+ times. Psychological distress was measured with the Kessler-6 scale using a cut-off score of 13+ indicating anxiety/depression symptoms. Multivariable modified Poisson and least-squares models were used to estimate the association between past-year cannabis use and psychological distress. Survey year and sex were tested as effect modifiers on the multiplicative and additive scales. The association between school grade of cannabis use initiation and psychological distress was also estimated.

Findings

From 2013 to 2023, the prevalence of psychological distress increased from 10.7% to 27.4%, whereas cannabis use decreased from 23.1% to 17.6%. Survey year and sex were statistically significant effect modifiers for the association between cannabis use and psychological distress with associations consistent with a super-additive effect but not multiplicative synergy (additive interactions: P < 0.05; multiplicative interactions: P > 0.05). The association between cannabis use and psychological distress strengthened over time, particularly for those using 40+ times compared with abstinence (from 0% [95% confidence interval (CI) = −6% to 6%] adjusted prevalence difference in 2013 to 18% (95% CI = 11%–25%] adjusted prevalence difference in 2023). Independent of time, there was evidence of dose–response among females, but not males. A 5% (95% CI = 1%–10%) lower prevalence of psychological distress was observed per later school grade of cannabis use initiation.

Conclusions

Psychological distress increased markedly among adolescents in Ontario, Canada, from 2013 to 2023. In that setting, adolescent cannabis use was statistically significantly associated with psychological distress, especially among females, and this association increased in magnitude over time, especially for those using most frequently. It is possible that adolescents are increasingly self-medicating psychological distress with cannabis and/or that rising cannabis potency is increasingly contributing to psychological distress. While causality cannot be established, based on the precautionary principle, policymakers should prioritize cannabis prevention strategies that aim to reduce frequency of use, limit potency and delay age of initiation, particularly among females.

Modelling the economic effects of reducing the consumption of unhealthy commodities: An inter‐sectoral input–output approach

Damon Morris, Duncan Gillespie, Megan James, Penny Breeze, Alan Brennan — Fri, 08 May 2026 08:06:35 -0700

Abstract

Aims

Industry arguments against public health policies that reduce the consumption of unhealthy commodities often include the assertion that the policy will harm the economy by reducing production and costing jobs. However, this argument does not consider that consumers may spend money previously used for unhealthy commodity consumption on other products, benefiting other sectors and potentially offsetting those negative economic consequences. In this study we aimed to estimate the macroeconomic impacts of reducing consumption of alcohol, tobacco, confectionary and gambling, accounting for reallocation of spending from these commodities to alternatives.

Method

We developed the open-source Commercial Determinants of Health Input–Output (CDOHIO) model version 1.1.0. CDOHIO models inter-sectoral linkages in the United Kingdom (UK) economy using published input–output tables to estimate the macroeconomic outcomes of changes in the total national consumer expenditure on selected unhealthy commodities and the reallocation of this expenditure to other consumption. We modelled a 10% decrease in total consumer expenditure on (1) alcohol, (2) tobacco, (3) confectionary and (4) gambling, assuming that the reduced expenditure was reallocated entirely to other products. The comparator in each case was no change in expenditure. We analysed six economic outcomes: (i) output (the total value of production in the economy), (ii) tax receipts from employees, (iii) tax receipts from employers, (iv) full-time equivalent employment, (v) total net earnings to individuals, and (vi) Gross Value Added (GVA), which is the primary outcome measure used as a proxy for national Gross Domestic Product.

Results

For tobacco, confectionary and gambling, reduced spending was estimated to yield positive effects across all six measures. The total effect of a 10% reduction in confectionary spending was an increase in GVA of £0.389 billion (0.02%), for reduced spending on tobacco, +£1.859 billion GVA (+0.09%) and for gambling +£1.250 billion GVA (+0.06%). For alcohol, a 10% reduction in spending led to a small negative effect on GVA (−£0.134 billion, −0.01%), which is the net effect of positive effects of reduced spending on off-trade alcohol (+£2.543 billion) and negative effects of reduced spending on on-trade alcohol (−£2.677 billion).

Conclusions

The potential negative macroeconomic impacts of reducing spending on tobacco, confectionary and gambling in the United Kingdom could be more than mitigated when consumers reallocate money spent on these products to other consumption. This is also the case for off-trade alcohol consumption, but not for on-trade alcohol consumption.

Understanding the interplay between alcohol use, cannabis use and mental health across the lifespan: A network analysis

Fri, 08 May 2026 00:00:00 -0700

Abstract

Aims

This study aimed to understand the interplay between alcohol use, cannabis use and mental health across the lifespan by addressing the following questions: (1) Do the structure and overall connectivity of mental health symptom networks differ between individuals who use alcohol and those who co-use alcohol and cannabis?; (2) Within co-users, what is the strength of the associations between characteristics of alcohol and cannabis use (quantity/frequency, severity of use-related problems and age of onset) and mental health symptoms?; and (3) Does age moderate these associations among co-users?

Design, setting and participants

Cross-sectional observational study including 740 participants aged 16–81 years, of which 446 used alcohol (57.6% female) and 294 co-used alcohol and cannabis (50.7% female). Data were collected online from English- and Dutch-speaking participants across multiple countries.

Measurements

Main outcome measures included self-reported severity of mental health symptoms (DSM-Level 1-Cross-Cutting Symptom Measure), quantity/frequency and problematic use of cannabis (Cannabis Use Disorder Identification Test - Revised) and alcohol (Alcohol Use Disorder Identification Test). Using a network approach, interactions between mental health symptoms (12 nodes) were compared between alcohol users and alcohol and cannabis co-users. In co-users, we incorporated detailed measures of alcohol and cannabis use (6 nodes) in the network and assessed the moderating role of age.

Findings

The alcohol and cannabis co-use group was characterized by higher quantity/frequency of use, problematic use and severity for all mental health symptoms compared with the alcohol group (Ps ≤ 0.001). Still, the alcohol use and alcohol-cannabis co-use networks did not statistically significantly differ (network invariance test: maximum difference in edge weights = 0.167, P = 0.611, global strength invariance test: global strength difference statistic = 0.265, P = 0.470), with both showing strong connections between anxiety, personality functioning and depression. However, the centrality invariance test revealed a statistically significantly (P = 0.018) higher strength of somatic symptoms in co-use (strength = 1.31) compared with alcohol use (strength = 0.17). When substance use outcomes were included in the co-use network, distinct associations emerged: alcohol-related problems were uniquely linked to anxiety, impaired personality functioning and suicidal ideation (partial cor. = 0.03, 0.01 and 0.01, respectively), while cannabis-related problems were associated with mania and dissociation (partial cor. = 0.05 and 0.02). Age did not moderate these relationships.

Conclusions

Alcohol use and alcohol-cannabis co-use appear to be associated with a range of mental health symptoms, including overlapping and distinct symptom patterns that are similar regardless of age.

Self‐harm in individuals with substance use disorders: Predictive factors and risk model

Thu, 07 May 2026 21:31:55 -0700

Abstract

Background and aims

Substance use disorders are associated with an elevated risk of self-harm. Currently, clinical and structured assessment of self-harm risk typically relies on evidence from the general population samples. The aim of this study was to develop a risk model for self-harm that incorporates predictors specific to individuals with substance use disorders.

Methods

Using national registers, we identified a population-based cohort of 449 720 individuals with substance use disorders in Sweden between 2006 and 2020. We tested independence and strength of a range of socio-demographic and clinical factors, obtained through linkage of population-based registers, with a Cox proportional hazards model, and estimated the risk of self-harm. For the risk model, 361 120 individuals were allocated to the development sample and 88 600 to external validation based on different geographical regions. We assessed self-harm risk over five predetermined follow-up periods—within 7 days, 1 month, 3 months, 6 months and 12 months—following a healthcare contact for substance use disorders.

Results

In the development sample, self-harm rates ranged from 0.6% to 3.5%, and in the validation sample from 0.5% to 3.6%. Ten risk factors were retained in the final risk model. Strongest associations with subsequent self-harm were for clinical factors: previous self-harm [hazard ratio (HR) = 3.17, 95% confidence interval (CI) = 3.08–3.26] and comorbidity of mental disorders (HR = 2.63, 95% CI = 2.50–2.72). Recent psychotropic medication use, including antidepressant (HR = 1.29, 95% CI = 1.23–1.38) and antipsychotic treatments (HR = 1.34, 95% CI = 1.24–1.44), was associated with increased risk, even after adjusting for psychiatric comorbidity, likely reflecting greater clinical severity and complexity. Across follow-up periods, performance was good in terms of discrimination, with area under the curve (AUCs) ranging from 0.73 (95% CI = 0.71–0.76) to 0.79 (95% CI = 0.78–0.80). In relation to calibration, expected-to-observed risk ratios were 1.00 to 1.04 and Brier scores 0.01 to 0.04 across follow-up periods. We used the model to generate a simple web-based risk calculator [Oxford Self-hArM after substance use disorders (OxSAMS)].

Conclusions

Modifiable clinical factors appear to have the strongest associations with increased risk of self-harm in people with substance use disorders. Structured tools, taking account of the different strengths of those factors, could inform clinical decision-making and provide a baseline assessment for training and research

Preventing lower‐level gambling harms: Shifting from individual‐ to system‐frame approaches

Robert M. Heirene — Thu, 07 May 2026 21:18:44 -0700

Abstract

Background

Gambling-related harm is not concentrated solely among individuals meeting criteria for problematic or disordered gambling. Tackling harm at a population level is essential to reducing the total burden of harm and preventing escalation to more severe harms. The public health approach to gambling recognises this and the need to address both individual and systemic factors that shape people's risk of harm. Despite this, research and policy in the field remain largely focused on interventions that target individual responsibility, such as educational messages, warnings, and voluntary tools.

Argument

Chater and Loewenstein's i-frame (individual-frame) and s-frame (system-frame) distinction provides a compelling basis for reorienting gambling harm prevention efforts. I-frame interventions target individual decision-making and self-regulation, while s-frame interventions seek systemic changes through restrictions and structural reforms. This paper argues that s-frame approaches are better suited to preventing gambling harms, particularly lower-level harms at the population level, because they [1] do not rely on individuals to recognise and effectively navigate the complex mathematical properties and potentially misleading features inherent in many gambling products, [2] apply universally without requiring individual engagement, and [3] can counter commercial interests without depending on consumer self-restraint. Reframing gambling harm prevention through the i−/s-frame lens offers conceptual clarity, highlights the opportunity costs of an overreliance on individual-focused interventions, and exposes incentives that perpetuate the status quo. This paper explains why i-frame approaches have dominated to date and how we can make the shift towards the s-frame.

Conclusions

Rather than abandoning i-frame approaches, research priorities should be rebalanced toward understanding, implementing, and evaluating systemic solutions. While i-frame interventions remain valuable for individuals seeking help, preventing population-level harms requires proportionate investment in structural solutions that make gambling products safer by design.

Cost‐effectiveness of in‐hospital motivational smoking cessation counselling and proactive referral to community‐based follow‐up

Thu, 07 May 2026 20:59:12 -0700

Abstract

Background and aim

In a randomised open-label trial among hospitalised patients with atherosclerotic vascular disease, motivational smoking cessation counselling with proactive referral to community-based follow-up was more effective than brief cessation advice and written information, with 6-month continuous abstinence rates of 49.5% vs. 24.5%. This study aimed to estimate the cost-effectiveness of this intervention compared with brief cessation advice.

Design

Economic evaluation alongside a multicentre, randomised open-label, blinded-endpoint trial with 1:1 randomisation.

Setting

Three secondary care hospitals in Norway. Recruitment took place from November 2021 to October 2023.

Participants

Hospitalised patients aged 18 years or older with established atherosclerotic vascular disease who reported smoking at least one cigarette daily before admission were eligible for participation, regardless of whether admission was planned or unplanned. A total of 221 patients were randomised. One participant withdrew informed consent and was excluded from all analyses, leaving 220 participants in the economic evaluation. The cohort comprised 40% women and the mean age was 65.2 years.

Measurements

Intervention costs included staff training, materials and personnel time. Hospital costs during the 16-month follow-up were estimated using Diagnosis-Related Group cost weights. Survival beyond follow-up was extrapolated using national mortality data adjusted for age, sex and atherosclerotic vascular disease. Lifetime costs were estimated using mean costs from the final six months of follow-up. The primary economic outcome was net monetary benefit (NMB), calculated at a willingness-to-pay threshold of €38 346 per life-year gained. The incremental cost-effectiveness ratio was also estimated. Future costs and life-years were discounted at 4%. Uncertainty estimates (UE) were obtained using bootstrapping.

Findings

During the 16-month follow-up, five patients (4.6%) died in the intervention group and nine (8.1%) in the control group. Discounted life expectancy from baseline was 13.54 years in the intervention group and 12.47 years in the control group, corresponding to an incremental gain of 1.06 life-years (95% UE = −0.72 to 3.31). The incremental discounted lifetime cost was €3280 per patient (95% UE = –€19 457 to €26 436), resulting in an incremental cost-effectiveness ratio of €3094 per life-year gained. At a willingness-to-pay threshold of €38 346 per life-year gained, the NMB was €37 475 (95% UE = –€15 868 to €107 797) and the probability of the intervention being cost-effective was 90.5%.

Conclusion

Motivational smoking cessation counselling delivered during hospitalisation with proactive referral to community-based follow-up had a high probability of being cost-effective from a hospital perspective for patients with atherosclerotic vascular disease.

Academic detailing is effective at altering clinician practice and patient outcomes for opioid use disorder

Jonathan Zhang, Jodie Trafton, Mark Bounthavong, Melissa Christopher — Thu, 07 May 2026 20:48:47 -0700

Addiction, EarlyView.

Are people who use methamphetamine at increased risk of physical violence? Results from a nationally representative sample

Christel Macdonald, Rebecca McKetin, Sergey Alexeev, Don Weatherburn — Wed, 06 May 2026 20:44:27 -0700

Abstract

Background and aims

The association between methamphetamine use and violent behaviour has received much attention in the research. The risk of violent victimisation among people who use methamphetamine is comparatively underexplored. People who use methamphetamine appear to be at a high risk of violent victimisation, but no studies have examined this association in a population-based representative survey. The aim of the current study was to examine the association between methamphetamine use and violent victimisation using a nationally representative sample of Australians.

Design

Observational study.

Setting

Australia.

Participants

18 805 individuals aged 15 years or over.

Measurements

Outcome variable: whether a respondent reported having been a victim of violence in the past 12 months. Exposure variable: frequency of methamphetamine use in the past 12 months (no use, every few months, monthly or more often). Co-variates: age, gender, financial stress, personal stress, long-term health condition, social isolation, cocaine use, drinking consumption, remoteness of area and survey year. Analyses were exploratory.

Findings

1.27% of the sample reported violence victimisation in the past 12 months, and 1.33% reported methamphetamine use (0.71% every few months; 0.62% monthly or more often). After adjusting for covariates, the odds of being a victim of violence in the preceding 12 months were higher for those who used methamphetamine every few months [adjusted odds ratio (aOR) = 5.94; 95% confidence interval (CI) = 1.95–18.06], and once a month or more often (aOR = 9.04; 95% CI = 3.48–23.45) than for those who had not used methamphetamine in the past year. Predicted probabilities indicated an estimated 11 709 (95% CI = 9473–13 953) excess violent victimisations attributable to methamphetamine use.

Conclusions

Methamphetamine use appears to be associated with an elevated risk of being a victim of violence. The population-level effects of methamphetamine use on violence may be small but are likely to have substantial public health implications in communities experiencing high levels of methamphetamine use.

Cross‐sectional and longitudinal associations of cannabis use with cognitive functioning in individuals with a cannabis use disorder: The moderating role of nicotine

Wed, 06 May 2026 16:09:01 -0700

Abstract

Background and Aims

Cannabis is among the most widely used psychoactive substances globally and is often consumed alongside tobacco. Cannabis use has been associated with impairments in attention, learning, and memory, whereas nicotine can acutely enhance, but chronically impair, certain cognitive functions. Most studies examine cannabis in isolation, leaving the cognitive impact of tobacco co-use unclear. This study aimed to estimate differences in cognitive performance between individuals with cannabis use disorder (CUD) and healthy controls, to determine whether cognition relates to heaviness of cannabis use or CUD symptom severity, to test moderation by daily tobacco use, and to assess whether baseline cognition was associated with cannabis outcomes one year later.

Design

Cross-sectional and one-year longitudinal study.

Setting

The Netherlands and Texas, USA.

Participants

A total of 231 participants aged 18–30 participated: 130 with CUD (57.7% male) and 101 controls (43.6% male).

Measurements

Participants completed tasks assessing interference control, attentional bias, sustained attention, executive functions, emotion recognition, delayed recall memory, working memory, and intelligence quotient (IQ). Primary outcomes were cognitive task scores; predictors included heaviness of cannabis use, CUD symptom severity, and daily tobacco use.

Findings

Compared with controls, individuals with CUD performed worse on interference control (rank biserial correlation [r_rank] = 0.080, p < 0.001), immediate recall memory (r_rank = 0.089, p = 0.009), delayed recall memory (r_rank = 0.090, p = 0.013), executive functions (r_rank = 0.089, p = 0.016), and estimated IQ (r_rank = 0.081, p < 0.001). Within the CUD group, cognitive performance was unrelated to heaviness of use or CUD severity. Before correction, daily tobacco use moderated the link between CUD severity and working memory (p = 0.011, unstandardized beta [B] = −1.83), with poorer performance observed only among non-tobacco users. Lower attentional bias (p = 0.027, B = −1.78) and sustained attention (p = 0.023, B = −27.88) were modestly associated with greater CUD severity at one-year follow-up.

Conclusions

Cannabis use disorder (CUD) appears to be associated with deficits in several cognitive domains independent of use intensity or severity. Tobacco and cannabis co-use appears to be related to relatively better working memory. Attention-related cognition appears to have limited associations with later CUD outcomes.

Efficacy and safety of transcranial direct current stimulation in alcohol use disorder: A randomized controlled triple‐blind trial

Wed, 06 May 2026 15:34:26 -0700

Abstract

Background and aims

Current treatment options for alcohol use disorder are limited. Transcranial direct current stimulation has been proposed as a therapeutic approach, but evidence remains scarce. This study aimed to compare active vs. sham transcranial direct current stimulation to evaluate its efficacy and safety in reducing alcohol consumption in a large sample of individuals with alcohol use disorder.

Design

REDSTIM is a triple-blind, randomized, sham-controlled trial that was conducted from October 2015 to January 2022. Participants were followed up every 4 weeks for 24 weeks.

Setting

Fourteen sites in France and Monaco.

Participants

356 adult outpatients with alcohol use disorder were assessed for eligibility, and 337 were enrolled and randomly assigned (1:1) to receive active or sham stimulation. At baseline, the randomized participants were primarily male (60.5%) with an average age of 51.3 ± 11.3 years.

Intervention and comparator

Two daily stimulation sessions (anode F4, cathode F3, 2 mA) delivered over five consecutive days vs. sham stimulation. Direct currents were applied via a pair of 0.9% NaCl-soaked surface sponge electrodes (25 cm²). In the sham stimulation group, the initial ramp-up time of 15 s (also up to 2 mA) was immediately followed by a ramp down phase of 30 seconds.

Measurements

The co-primary outcomes were the change in the number of heavy drinking days (HDD) and total alcohol consumption (TAC) over the follow-up period. Exploratory secondary outcomes included alcohol craving, clinical and biological improvements, quality-of-life, mood, cognitive and safety assessments.

Findings

Over 24 weeks of follow-up, vs. sham, the active stimulation group reported statistically significant reductions in the number of HDD [−2.45 HDD/4 weeks, 97.5% confidence interval (CI) = −4.86 to −0.05, P = 0.022]. The reduction in TAC was not statistically significant (−5.96 g/day, 97.5% CI = −15.18 to 3.26, P = 0.147). The interpretation of these findings should take into account the proportion of missing data related to alcohol diary completeness and losses to follow-up.

For secondary outcomes at 24 weeks, vs. sham, craving assessments were lower in the stimulation group (−0.36 95% CI = −0.65 to −0.07, P = 0.016), as were carbohydrate deficient transferrin levels (−0.33 95% CI = −0.65 to −0.01, P = 0.045). In the active vs. sham stimulation group, 69 (41.1%) and 62 participants (36.7%) experienced one or more adverse effects, resulting in 6 dropouts.

Conclusions

Among adult outpatients with alcohol use disorder, active transcranial direct current stimulation resulted in a modest but sustained reduction in heavy drinking days over 24 weeks, while no statistically significant effect was observed for total alcohol consumption. The intervention was well tolerated.

The feasibility of mindfulness‐based relapse prevention for adults with substance use disorders (illicit drugs) in a Chinese population: A pilot randomized controlled trial

Thu, 30 Apr 2026 01:10:56 -0700

Abstract

Background and aims

Mindfulness-based relapse prevention (MBRP) has been shown to be beneficial to individuals with substance use disorder (SUD) in the West. The current pilot study aimed at testing the feasibility of MBRP in a Chinese population.

Design

This pilot study adopted a design of randomized controlled trial comparing MBRP with treatment-as-usual group (TAU).

Setting

Participants were recruited from residential detox centers, community addiction counseling centers and substance abuse clinics specialized addiction treatment clinics in Hong Kong.

Participants

A total of 81 adults (85.2% male) with SUD (illicit drugs only) were recruited.

Interventions

The intervention group participants (n = 41) attended a 1-hour orientation session followed by 2-hour weekly MBRP sessions for 8 weeks, delivered by a qualified MBRP teacher. The TAU group participants (n = 40) continued their service received from their referral agency. (After completion of all study assessments they were offered the same 8-week MBRP course.)

Measurements

Feasibility was measured by attendance, course satisfaction and retention rate. Participants' change in substance use and other related outcomes were captured by self-reported drug use, urine drug tests and a list of psychometric scales at baseline, immediately after MBRP and 3- and 6-month follow-up.

Findings

The MBRP course satisfaction was high, and the attendance (57.4%) and retention rates (63.4%–85.4%) were comparable to previous trials. No statistically significant differences were observed between the MBRP and TAU groups for any outcomes, including craving, depression, anxiety, mindfulness and health-related quality of life; however, improvement trends were noticed in the MBRP group in self-efficacy in managing high-risk situations at post intervention, as well as in addiction severity and psychological flexibility at the 6-month follow-up.

Conclusions

Mindfulness-based relapse prevention was shown to be feasible for substance use disorder treatment in a Chinese population. In this small study there was only limited evidence of abstinence efficacy, and no evidence of a benefit on other secondary outcomes.

Lower risk drinking guidelines and the ‘no safe level’ message: Finding a balance in risk communication

Robyn Burton, James Nicholls — Thu, 30 Apr 2026 01:04:35 -0700

Addiction, EarlyView.

Discrimination experiences are associated with same‐day and next‐day smoking among adults with low socio‐economic status trying to quit: A secondary analysis of data from a randomized clinical trial

Thu, 30 Apr 2026 00:44:37 -0700

Abstract

Background and aims

Research indicates that experiencing discrimination may be associated with a return to smoking following a quit attempt. The current study aimed to characterize day-to-day relations between discrimination and smoking in the context of a smoking cessation trial for adults with socio-economic disadvantage.

Design

Secondary analysis of data from a randomized controlled trial, which used a parallel 2-group design (unblinded). Eligible participants (adults with socio-economic disadvantage) were randomly assigned to usual care (UC) for smoking cessation (counseling and pharmacotherapy) or UC plus financial incentives contingent on biochemically verified abstinence. All participants were asked to complete daily smartphone assessments over the first 28 days following a scheduled quit attempt.

Setting

The smoking cessation trial (parent study) was conducted in a tobacco treatment clinic between 2017 and 2022 in Oklahoma City, Oklahoma, USA.

Participants

Participants (n = 256) were primarily female (64.8%) and 40.6% were racially/ethnically minoritized. The average age was 48.97 [standard deviation (SD) = 11.61] years. The average cigarettes smoked per day before quitting was 19.00 (SD = 10.51).

Measurements

Smartphone assessments measured discrimination [“Do you believe you experienced discrimination yesterday?” (yes/no)] and self-reported daily smoking [“How many cigarettes did you smoke yesterday?” (smoking [≥one puff]/abstinent)]. Biochemically verified past 7-day smoking status was assessed at the 4, 8, 12 and 26 week post-quit follow-ups. Generalized linear mixed models analyzed the relations between (1) same-day and next-day discrimination and abstinence and (2) reporting any discrimination during the smartphone assessment period (SAP) and biochemically verified abstinence at follow-ups.

Findings

Overall, 62 participants (22.4%) reported 212 instances of discrimination over the SAP. Discrimination was statistically significantly associated with lower odds of same-day [β = 0.48, 95% confidence interval (CI) = 0.25–0.94] and next-day (β = 0.47, 95% CI = 0.25–0.86) abstinence, and any discrimination during the SAP was statistically significantly associated with lower odds of abstinence across follow-ups (β = 0.08, 95% CI = 0.02–0.30).

Conclusions

Experience of discrimination appears to adversely impact smoking cessation among adults with socio-economic disadvantage who are trying to quit smoking and warrants attention in cessation interventions.

Trial Registration: The parent trial was registered at ClinicalTrials.gov (NCT02737566). The secondary analyses described in this manuscript were not pre-registered.

Age period cohort trends in alcohol treatment episodes across Australia from 2003 to 2022

Wed, 29 Apr 2026 23:36:29 -0700

Abstract

Aims

To measure trends in alcohol treatment episodes in Australia, disaggregated by age, period and birth cohort.

Design and setting

Age, period, cohort modelling with restricted cubic splines, using Australian alcohol treatment administrative data from July 2002 to June 2022.

Participants

1 253 548 closed treatment episodes where alcohol was the primary drug of concern from people aged 10 to 100 years who received treatment for their own substance use in publicly funded specialist alcohol and other drug treatment services.

Measurements

Count of alcohol treatment episodes by age, period, birth cohort and sex.

Findings

Alcohol treatment episode rates increased over time, peaking in 2022 (330.11 per 100 000 population). Age trends first peaked at around 21 years of age [cross-sectional prevalence = 444.30, 95% confidence interval (CI) = 440.82–447.80; longitudinal prevalence = 462.45, 95% CI = 458.06–466.89], followed by a lifetime peak between 37 and 44 years and declining with older age. Cohorts born from 1974 to 1979 had the highest alcohol treatment episode rates, and the oldest and youngest birth cohorts had the lowest alcohol treatment episode rates. Males were overall 1.8 times as likely as females to have an alcohol treatment episode, but this gap closed with more recent birth cohorts.

Conclusions

Alcohol treatment episode rates increased in Australia between 2003 and 2022, and particularly from 2017. Young to middle-aged adults and people born in the 1970s were most at risk, alongside a persistent but narrowing gap between males and females.

Context, mechanisms and outcomes of a social enterprise model of residential rehabilitation for problem substance use: A realist‐informed process evaluation

Martin Anderson, Lucy Pickering, Mark McCann — Wed, 29 Apr 2026 23:09:52 -0700

Abstract

Background and aims

This study evaluated a three-year residential rehabilitation programme, which aimed to support recovery from problem substance use via peer support and social enterprise activities. The aims were to clarify programme mechanisms and identify contextual factors associated with variation in outcomes.

Methods

The study took place within River Garden, a residential rehabilitation for problem substance use, based in South Ayrshire, Scotland. A mixed-methods realist-informed process evaluation was undertaken, using participant observation, repeated qualitative interviews and routinely collected admissions data. Fieldwork was conducted with residents, staff and trustees between April 2019 and November 2020. Nine (of ten) residents were recruited into the study. All residents were male, aged 20–47 years (median 35 years) and were White Scottish or English. Data collection and analysis was guided by Medical Research Council guidance on process evaluation and informed by selected principles from realist evaluation.

Results

Three key contextual factors and six key mechanisms were associated with variation in resident outcomes. The severity of residents' substance use problems, their physical and mental health and their socioeconomic backgrounds shaped whether they responded to the programme's instrumental and relational resources with trust, respect or motivation (constituting six mechanisms, e.g. instrumental-respect, relational-trust). The programme was most beneficial for residents for whom intended outcomes were less constrained by contextual moderators.

Conclusions

In residential rehabilitation for substance use disorders, residents with higher problem severity, worse physical and mental health and greater socioeconomic disadvantage appear to be less likely to respond to rehabilitation resources with trust, respect or motivation compared with the other residents. These findings may support the development of strategies to improve outcomes for residents with greater contextual barriers to change.

‘If you've ever experienced it, you'd feel differently’: Exploring willingness and skepticism toward using higher dose naloxone products among people who use drugs in Maryland, United States

Wed, 29 Apr 2026 05:25:04 -0700

Abstract

Background and aims

Higher dose naloxone products (HDN) have recently been approved and marketed in the United States; however, evidence on the relative advantage of these products to standard 4 mg products has not been substantiated by prior research. People who use drugs are the primary beneficiaries and consumers of naloxone products. This study aimed to characterize their willingness to use HDN products and technical understanding of these products.

Design and measurements

We conducted in-depth interviews with syringe service program clients following an interview guide. Interviews were recorded and transcribed before being analyzed using a hybrid deductive-inductive qualitative approach.

Setting

Interviews were conducted in partnership with community-based syringe service programs in three distinct regions of the state of Maryland, USA: a rural county, Baltimore city and a surrounding suburban community.

Participants

Twenty-two interviews were completed. All participants had used opioids and responded to an overdose using naloxone in the past 3 months. The majority of participants were men (73%), non-Hispanic white (64%) and currently experiencing housing instability (59%).

Findings

Participants demonstrated high willingness to use HDN, motivated by volatility in the local drug supply and perceived inefficiency of naloxone against potent synthetic opioids. Participants believed that the relative advantage of HDN was that it would reverse overdoses more quickly than existing products; however, many participants wanted increased control in overdose situations, including the ability to titrate and combine dosages to reduce the severity of precipitated withdrawal. Skepticism towards HDN products was rooted in general skepticism of pharmaceutical companies, as well as the belief that perceptions of lower dose naloxone being ineffective could be attributed to user error.

Conclusions

Development of novel overdose reversal products should be informed by the experiences of primary consumers and beneficiaries of these products. A high level of transparency is needed in the marketing of these products to promote consumer trust and confidence in their safety and utility.

Nation‐wide trends in prevalence and mortality of high‐risk drinking among adult men with and without disabilities in South Korea between 2009 and 2017

Bo Hui Park, So Young Kim, Kyoung Eun Yeob, Yeon Yong Kim, Jong Hyock Park — Tue, 28 Apr 2026 03:12:55 -0700

Abstract

Background and aims

Excessive alcohol consumption contributes substantially to the global burden of disease, yet population-level evidence on disparities in high-risk drinking among people with disabilities remains limited. We aimed to estimate and compare trends in the prevalence of high-risk drinking and all-cause mortality associated with drinking behavior among men with disabilities and those without disabilities.

Design

Nation-wide serial cross-sectional study.

Setting

South Korea, using linked administrative national health check-up and mortality databases.

Participants

A total of 7 551 340 adult men who participated in the National Health Insurance Service health check-up program in 2017, including 450 536 men with registered disabilities and 7 100 804 men without disabilities.

Measurements

High-risk drinking was defined as consumption of seven or more standard drinks per occasion at least twice per week, based on self-reported health check-up questionnaires. Age-standardized prevalence of high-risk drinking was estimated annually from 2009 to 2017. Associations between disability characteristics and high-risk drinking were estimated using multivariable logistic regression in 2017. All-cause mortality occurring within 2017 was ascertained through deterministic linkage to the national death registry using unique personal identifiers.

Findings

In 2017, age-standardized prevalence of high-risk drinking was 17 141 per 100 000 among men with disabilities and 23 226 per 100 000 among men without disabilities. Among men aged 20–49 years, prevalence was 29 710 per 100 000 in those with mild disabilities and 26 332 per 100 000 in those without disabilities. In 2017, compared with men without disabilities, mild disability was associated with higher odds of high-risk drinking [adjusted odds ratio (aOR) = 1.12, 95% confidence interval (CI) = 1.11–1.13], whereas brain injury was associated with lower odds (aOR = 0.61, 95% CI = 0.58–0.65). In 2017, age-standardized mortality rates were 131.4 per 100 000 among non-drinkers, 99.2 among high-risk drinkers, 77.3 among moderate drinkers and 59.9 among low-risk drinkers. Across drinking categories, several disability groups had adjusted odds ratios greater than 1.0 for all-cause mortality compared with those for men without disabilities within the same drinking category.

Conclusion

High-risk drinking prevalence among South Korean men was lower among those with disabilities than among those without disabilities from 2009 to 2017, with declining trends in both groups. High-risk drinking prevalence among South Korean men appears to differ by disability characteristics. Mortality odds ratios within drinking categories vary by disability type and severity when compared with men without disabilities in the same drinking category.

The psychometric properties of validated tools to assess cannabis use disorder: A systematic review and meta‐analysis

Tue, 28 Apr 2026 01:15:57 -0700

Abstract

Aims

To systematically review the evidence on the psychometric performance and accuracy of screening or diagnostic tools for cannabis use disorder.

Method

Systematic review and meta-analysis which included studies conducted in clinical settings, schools, universities, community settings and population-based surveys in multiple countries and regions. Participants were adolescents, young adults, general adult populations, people who used cannabis, psychiatric and substance use treatment attendees, and specialised groups such as justice involved youth and military personnel. The tools assessed included The Cannabis Abuse Screening Test (CAST), the Cannabis Use Disorders Identification Test–Revised (CUDIT-R), the Severity of Dependence Scale (SDS), the Cannabis Problems Questionnaire (CPQ), the Cannabis Problems Questionnaire for Adolescents (CPQ-A), the Cannabis Use Problems Identification Test (CUPIT), the Tobacco, Alcohol, Prescription medication, and other Substance use tool (TAPS), the Marijuana Screening Inventory–X (MSI-X), the DSM-Guided Cannabis Screen, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), the Marijuana Problem Index (MAPI), the Toronto Cannabis Risk Screening Tool (TCRUST), the Nigerian Cannabis Use Disorder Scale, and the Problematic Use of Marijuana measure (PUM). These were assessed for internal consistency, test–retest reliability, as well as diagnostic accuracy using measures of sensitivity, specificity and area under the curve (AUC).

Results

Forty studies met inclusion criteria (2000–2025), including data from N = 23 175 participants. Methodological quality was generally moderate to high, though some studies relied on self-reported symptom checklists rather than structured diagnostic interviews. The most frequently studied tools were the CAST (k = 13 studies), CUDIT-R (k = 8), SDS (k = 5), CPQ and CPQ-A (k = 4), and CUPIT (k = 2). Across instruments, internal consistency was generally acceptable to excellent (α = 0.66–0.92), with fair to excellent discriminative validity (AUC = 0.71–0.96) for detecting cannabis use disorder or dependence. Optimal cut-offs varied statistically significantly by population and setting. In clinical samples, the tools generally performed stronger with the use of standard or higher cut-offs to prioritize specificity and avoid misclassifying non-cases. In general population samples, particularly youth, the tools had better performance with lower cut-offs to prioritize sensitivity.

Conclusions

There is a lack of sufficient studies on screening or diagnostic tools for cannabis use disorder for clear evidence. Based on this limited current evidence, several brief screening or diagnostic tools are useful in identifying disorder or problem cannabis use in diverse settings, including the CAST, CUDIT-R, and SDS. Variation in optimal thresholds by age, clinical status and cultural context suggest that the utility of these screening or diagnostic tools depends on the population.

Evaluating comparative effect of non‐pharmacological interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta‐analysis

Tue, 28 Apr 2026 00:50:24 -0700

Abstract

Background and aims

Non-pharmacological therapies are critical for disease management, particularly when pharmacological approaches are limited. Investigating their role as adjuncts to pharmacotherapy to improve outcomes in opioid use disorder (OUD) is of substantial clinical importance. This study aimed to evaluate the efficacy of non-pharmacological therapies as adjuncts to opioid agonist therapy (OAT) management for OUD.

Methods

We systematically searched PubMed, Cochrane Controlled Register of Trials, Embase and Web of Science from inception to 8 February 2025 for randomized controlled trials (RCTs) comparing OAT alone versus OAT combined with non-pharmacological interventions in OUD. Outcomes of interest included treatment retention [assessed via odds ratios (ORs)], negative urine test results (specimen and the longest duration of continuous drug abstinence) and opioid craving scores [both evaluated via standard mean differences (SMDs)]. Bayesian network meta-analysis (NMA) using a random-effects consistency model was conducted to compare the relative effects of all non-pharmacological interventions. Local inconsistency was evaluated through node-splitting analysis, and global inconsistency was assessed using the non-consistency model. The certainty of the evidence was assessed using the GRADE framework (Grading of Recommendations, Assessment, Development and Evaluation) for network meta-analysis.

Results

Forty-two RCTs involving 5113 participants were included. For treatment retention, contingency management (CM) combined with OAT likely results in an increase [low-certainty evidence; OR = 1.64, 95% credible interval (CrI) = 1.03–2.57], while the combination of OAT with contingency management plus cognitive behavioral therapy (CBT + CM; very low-certainty evidence; OR = 2.47, 95% CrI = 1.10–5.67) or with enhanced methadone services (EMS; very low-certainty evidence; OR = 5.48, 95% CrI = 1.47–22.61) may result in an increase, compared with OAT alone. No intervention statistically significantly improved opioid-negative urine tests over OAT alone (very low certainty). For craving, acupuncture (very low certainty; SMD = −2.13, 95% CrI = − 3.09 to −1.15) and sham acupuncture (low certainty; SMD = −1.49, 95% CrI = − 2.69 to −0.31) combined with OAT may reduce craving scores.

Conclusion

Contingency management, as adjunctive therapies for opioid agonist therapy (OAT), may improve treatment retention in patients with opioid use disorder compared with traditional OAT. Enhanced methadone services and contingency management plus cognitive behavioral therapy may improve treatment retention too but the evidence is very uncertain. Compared with OAT, sham acupuncture as an adjunct therapy may help reduce opioid cravings; acupuncture may reduce cravings too but evidence is very uncertain.

Substance‐related intrusive memories in cocaine use disorder are different from but associated with craving

Mon, 27 Apr 2026 16:39:50 -0700

Abstract

Background and aims

Cocaine use disorder (CUD) is a significant global health concern, characterized by persistent craving despite severe consequences. Recent theories highlight maladaptive memory processes – such as intrusive, vivid recollections of past substance use that arise spontaneously in daily life – as key contributors to craving and relapse; however, empirical studies examining such substance-related intrusions in naturalistic contexts remain scarce. This study therefore used ecological momentary assessment (EMA) to investigate the frequency, phenomenology and emotional and behavioural correlates of substance-related memory intrusions in individuals with CUD, and how these relate to craving, cocaine use severity (CUS) and psychotherapy experience.

Design

A 14-day EMA study captured event-based reports of intrusions, craving and related experiences in participants diagnosed with CUD.

Setting

The study was conducted in Switzerland in a naturalistic setting, with data collected via individuals' smartphones.

Participants

N = 43 participants (recruited in Switzerland, 16% female; 18–59 years old, median compliance rate 82.8%) with a current DSM-5 diagnosis of CUD made a total of n = 360 event-based reports that were analysed.

Measurements

EMA reports included intrusion episode types (pure intrusions, intrusions with subsequent or simultaneous craving or pure craving), intrusion characteristics (vividness, intrusiveness, modalities), craving intensity, episode triggers and cognitive-behavioural, emotional and physiological responses. CUS was assessed based on use quantity, duration and obsessive-compulsive use symptoms.

Findings

Participants recorded an average of 8.4 episodes (standard deviation = 5.8) across 14 days. Intrusions frequently occurred independently of craving (42.4%) but were statistically significantly associated with greater craving intensity when more vivid (unstandardized regression coefficient b = 0.53, P = 0.002) and intrusive (b = 0.48, P < 0.001). Episodes involving craving were characterized by greater distress (b = 1.52–2.17, all P < 0.001) and greater loss of control (b = 2.41–3.22, all P < 0.001) and were associated with higher odds of reporting obtaining cocaine (odds ratio = 19.90, P < 0.001). Higher CUS predicted more frequent intrusion episodes (unstandardized regression coefficient β = 0.52, P < 0.001), while psychotherapy experience was associated with lower vividness (b = −1.45, P = 0.008), intrusiveness (b = −1.33, P = 0.004) and craving intensity (b = −1.56, P = 0.010).

Conclusions

Substance-related memory intrusions in people with cocaine use disorder are distinct cognitive-affective events that often occur independently of craving but are closely linked to its intensity, particularly when experienced as vivid and emotionally charged. Targeting these features through behavioural or pharmacological interventions may help mitigate craving-driven distress and impulsive use-related behaviour.

High temporal resolution monitoring of illicit drug consumption across England via wastewater analysis

Sun, 26 Apr 2026 16:01:08 -0700

Abstract

Aim

To monitor community-level consumption of 20 illicit drugs across urban areas of England using wastewater-based epidemiology (WBE) surveillance at high temporal resolution.

Design, setting, cases

This study was conducted over a 12-month period in 2022 sampling 24-hour composite wastewater samples at 15 wastewater treatment plants (WWTPs) covering catchment population equivalents ranging from ~100 000 to >1 million. Analysis was conducted using rapid liquid chromatography–tandem mass spectrometry methods. The sampled WWTPs collectively covered 21% of the national population.

Measurements

Primary data outcomes were the population-normalised daily loads (PNLs) entering the WWTP, estimated population-normalised consumption (both in mg/1000 people/day) and total mass (g/day) of 20 targeted illicit drugs and total mass in each catchment, quantified using suitable drug target residue markers in 1746 wastewater samples. Covariables included temporal indicators (e.g. public holidays, events) and regional factors. Presence, quantity and correlation of WBE-derived drug use data were used to infer drug use patterns.

Findings

Of the 20 illicit drugs investigated, 18 were detected in at least one sample. Cocaine exhibited the highest average daily PNL (2770 ± 829 mg/1000 people/day), followed by heroin (382 ± 248), ketamine (287 ± 183), amphetamine (272 ± 268), 3,4-methylenedioxymethamphetamine (MDMA) (80 ± 57) and methamphetamine (60 ± 99) across 2022. When comparing PNLs to Sewage analysis CORe group—Europe (SCORE) and European Drugs Agency WBE data for 109 other WWTPs across Europe from March to May, 2022 cocaine and ketamine PNLs from sites in England were ranked statistically higher [cocaine: Wilcoxon rank-sum test statistic (W) = 971, adjusted P = 0.000115; ketamine: W = 264, adjusted P = 0.0000389]. Importantly, seven English WWTPs recorded higher mean ketamine PNLs than any other European site over the same period in 2022. Temporal spikes in drug consumption aligned with public holidays and major events. A notable decrease in cocaine use coincided with a 3.7-t UK seizure. Strong inter-drug correlations were observed across catchments, particularly for benzoylecgonine/ketamine and benzoylecgonine/cocaethylene. Extrapolation to generate a representative national average consumption estimate is not recommended, as the WWTPs studied were mostly classified as urban areas and found not to be representative of the entire population of England.

Conclusions

Wastewater analysis revealed widespread and temporally variable illicit drug use across England in 2022, with ketamine use exceeding European levels at multiple sites. The findings highlight wastewater-based epidemiology's capacity to monitor drug use trends and identify community-level impacts of interventions and events.

Working with, learning from and giving back: Principles for collaborative research with people who use drugs

Magdalena Harris — Fri, 24 Apr 2026 06:59:28 -0700

Addiction, EarlyView.

‘Emptiness filled with love’: A reflexive thematic analysis of chemsex trajectories among gay, bisexual and other men who have sex with men in Almaty, Kazakhstan, using a life course framework

Nikolay Lunchenkov, Nadezhda Cherchenko, Elena German, Susanna Rinne‐Wolf — Fri, 24 Apr 2026 06:43:09 -0700

Abstract

Background and aims

The intentional use of psychoactive substances to enhance sexual experiences, known as chemsex, is associated with human immunodeficiency virus (HIV) transmission, psychological distress and social isolation among gay, bisexual and other men who have sex with men (GBMSM). While research has predominantly focused on high-income countries, gaps remain in our understanding of the dynamics in Eastern Europe and Central Asia, where structural homophobia, restrictive drug policies and limited healthcare access uniquely shape chemsex-related risks. There is limited research on how chemsex engagement evolves over time. This study aimed to identify the stages of chemsex engagement and examine how social, psychological and structural factors shape transitions between these stages among GBMSM in Kazakhstan.

Methods

This study is a secondary analysis of data from a cross-sectional qualitative study conducted in Almaty, Kazakhstan, between July and September 2023. Twenty-one GBMSM who had engaged in chemsex within the past 12 months participated in semi-structured interviews lasting between 60 and 90 minutes. All participants reported using mephedrone and/or alpha-PHP (α-Pyrrolidinohexiophenone). Deductive reflexive thematic analysis, guided by Life Course Theory, was used to reconstruct chemsex trajectories from retrospective participant accounts.

Results

Five distinct themes related to different trajectory stages were developed. Initiation occurred through trusted social networks in intimate settings, taking the form of unplanned encounters that fulfilled emotional needs for connection and belonging. Maintenance was characterised by self-imposed temporal and dosage limits; however, participants reported a decline in satisfaction with sober sex. Escalation involved a breakdown of protective boundaries, an increased frequency and quantity of use and a deeper involvement in chemsex social networks, despite mounting physical and psychological consequences. Dependence was characterised by a narrowed agency under escalating constraints, with substance use shifting from enhancing pleasure to coping with withdrawal, resulting in substantial impairment across life domains. Disengagement attempts described recursive trajectories with diverse recovery goals ranging from cessation to managed use. Sustained abstinence was rare and dependent on affirming care and supportive resources. Throughout all stages, structural stigma constrained individual agency, while chemsex networks provided crucial emotional safety that was unavailable in mainstream environments.

Conclusions

Chemsex trajectories among gay, bisexual and other men who have sex with men in Kazakhstan represent dynamic processes shaped by the interaction between individual agency and structural constraints, in which substance use functions as an emotional regulation strategy and a social survival strategy in contexts of high stigma.

Drug sellers' use of a drug checking service amid the overdose crisis in British Columbia, Canada

Fri, 24 Apr 2026 06:16:26 -0700

Abstract

Aims

This study examined the use of a drug checking service by drug sellers in British Columbia, Canada, to assess motivations for service use and substances intended for distribution, focusing on risks associated with an unstable illicit drug market.

Design

A retrospective analysis was conducted using data from an anonymous intake survey and drug checking results. The survey captured frequency of service use, expected substances and reasons for service access.

Setting

The study was set in Victoria, British Columbia, where participants accessed a free confidential drug checking service between January 2021 and December 2024.

Participants

A total of 2332 drug sellers were included in the analysis, accounting for 16.2% of all service users. They submitted 5528 samples (21.6% of total samples), averaging 2.4 samples per visit, compared to 1.7 among non-sellers.

Measurements

The primary outcomes measured included the frequency of drug check use, the expected and actual composition of the samples, pre- or post-consumption analysis and the reasons for engaging with the service. Secondary outcomes focused on the reported potency and the presence of unexpected substances.

Findings

A statistically significant portion of sellers continuously used the service, particularly for opioid samples, which comprised 69.2% of seller submissions compared with 35.1% among non-sellers [X² (1, n = 20 864) = 2055.57, P < 0.001]. Sellers reported using the service to mitigate risks associated with the illicit drug market, including overdose, showing a proactive interest in ensuring the safety of their customers. Despite greater confidence in the composition of their products, sellers were less likely than non-sellers to have their samples confirmed as “expected” [38.4% vs. 51.9%; X² (1, n = 12 520) = 313.76, P < 0.001]; unexpected substances were detected in 44.8% of their samples. Notably, protective strategies employed by sellers were identified, demonstrating the role of drug checking as a supply-focused harm reduction intervention.

Conclusions

In Victoria, British Columbia, drug sellers appear to be increasingly using drug checking services as a preventive measure, positioning them as potential partners in harm reduction efforts.

Profiles of youth initiating use of nicotine pouches, vapes and cigarettes: National findings from the Population Assessment of Tobacco and Health (PATH) study, 2022–2023

Olufemi Erinoso, Karin Kasza — Fri, 24 Apr 2026 06:00:06 -0700

Abstract

Background and aims

Nicotine pouches have risen in appeal and use among United States (U.S.) youth and young adults. However, less is known about the initiation determinants of pouch use, and how they compare with those of e-cigarettes or cigarettes. This study compared the demographic, behavioral, and exposure profiles of adolescents and young adults (AYAs) who initiated nicotine pouch-use with those who initiated nicotine vaping and those who initiated smoking in a nationally representative U.S. cohort.

Design and settings

We used a longitudinal study design. The study setting was the United States (US) with data from the Population Assessment of Tobacco and Health (PATH) Study (Waves 7 and 7.5, 2022–2023).

Participants

AYAs aged 12–22 (n = 14 326).

Measurements

The primary outcomes at follow-up were initiation of nicotine pouches (never use [2022] to ever use [2023]), vaping, and cigarette smoking. Study predictors at baseline (2022) included demographics, substance and tobacco use, mental health, and social and behavioral exposures. As a secondary objective, susceptibility to vape or smoke at baseline was examined as a predictor of pouch initiation. Separate multi-variable logistic regression models assessed factors associated with the initiation of each product.

Findings

The study population comprised 50.6% males, and 45.4% were between the ages 18–22 years, 15–17 years (21.2%), and 12–14 years (33.4%). In 2023, initiation rates were 2.4% for pouch use, 6.2% for vaping, and 3.2% for smoking. Current smoking at baseline was associated with initiating pouch use (adjusted odds ratio [AOR] = 2.8, 95% confidence interval [95% CI]: 1.7–4.4) and initiating vaping (AOR = 5.3, 95% CI: 2.0–13.7) at follow-up. Current vaping was associated with higher odds of pouch initiation (AOR = 7.9, 95% CI: 5.1–12.4), but current pouch use was not associated with vaping initiation (AOR = 2.4, 95% CI: 0.3–16.2) at follow-up. Having important peers who use pouches (vs. none) was associated with pouch initiation (AOR = 2.2, 95% CI: 1.2–4.3), similarly for vaping but not for smoking at follow-up. Among pouch initiators (n = 335), most vaped nicotine at follow-up (37.9%), 19.7% vaped nicotine and smoked, and 5.2% smoked cigarettes and did not vape.

Conclusions

Cigarette smoking appears to be associated with both nicotine pouch initiation and vaping initiation among United States adolescents and young adults. Current vaping appears to be associated with pouch initiation, but current pouch use does not appear to be associated with vaping initiation. Important peers using pouches appear to be associated with pouch initiation and vaping initiation but not cigarette smoking. Most pouch initiators in this study concurrently vaped at one-year follow-up.

Characterizing public comments via Regulations.gov in response to proposed cannabis rescheduling in the United States

Fri, 24 Apr 2026 05:45:55 -0700

Abstract

Aims

The United States Drug Enforcement Administration's (DEA) proposed rescheduling of cannabis from Schedule I to Schedule III under the Controlled Substances Act marks a significant shift in federal policy. Understanding public sentiment toward this policy is critical for guiding the current cannabis rescheduling effort as well as future reforms. The objective of this study is to characterize public comments submitted to Regulations.gov regarding the DEA's cannabis rescheduling proposal and identify underlying justifications for support or opposition.

Design

A mixed-methods analysis was conducted.

Setting

Online public comments submitted to Regulations.gov regarding the DEA's cannabis rescheduling proposal.

Participants

42 913 public comments submitted between 21 May and 22 July 2024.

Measurements

Comments were analyzed for sentiment towards the proposed rescheduling (support, oppose or insufficient rescheduling) and thematic justifications using manual and automated natural language processing techniques. A two-stage annotation approach was employed: manual coding of 200 randomly sampled comments by multiple independent evaluators, followed by automated classification of all 42 913 comments using open source Large Language Model (LLM) validated against the manual annotations.

Findings

Using LLM-based classification validated against human annotations [88% agreement, F1 (harmonic mean of precision and recall) = 0.86], we found that among 42 913 comments, 28.85% [95% confidence interval (CI) = 28.44%–29.24%] supported rescheduling, 6.74% (95% CI = 6.50%–6.99%) opposed and 63.50% (95% CI = 63.06%–63.99%) deemed the proposal insufficient, favoring further rescheduling or complete de-scheduling of cannabis. Among the 200 manually annotated comments, therapeutic benefits (56.7%, 95% CI = 46.7%–66.7%) and economic impacts (27.8%, 95% CI = 18.9%–37.8%) were the most common justifications among supporters. Public health risks (100.0%, 95% CI = 100.0%–100.0%), addictiveness concerns (71.4%, 95% CI = 42.9%–100.0%) and concerns about underage use (57.1%, 95% CI = 14.3%–85.7%) were predominant in opposing comments. Insufficient rescheduling comments cited therapeutic benefits (37.8%, 95% CI = 28.5%–48.0%), economic impacts (28.6%, 95% CI = 19.4%–37.8%) and criminal justice reform (26.5%, 95% CI = 18.4%–35.7%) as primary justifications.

Conclusions

Public sentiment on Regulations.gov supports the United States Drug Enforcement Administration's proposal for cannabis rescheduling, though the majority views the proposed Schedule III classification as inadequate and supports further rescheduling or complete de-scheduling of cannabis.

Correction to “Offering e‐cigarettes for smoking cessation and reduction in people with mental illness (ESCAPE): Protocol for a randomized controlled trial”

Thu, 23 Apr 2026 03:17:05 -0700

Addiction, EarlyView.

Understanding purchasing patterns of alcoholic, alcohol‐free and low‐alcohol drinks: A latent profile analysis

Oscar Rousham, Abigail K. Stevely, John Holmes — Thu, 23 Apr 2026 02:37:12 -0700

Abstract

Background and aim

Alcohol-free and low-alcohol (no/lo) drinks (≤1.2% ABV) are increasingly popular in high-income countries. Their potential to reduce alcohol-related harm depends on who buys them, in what quantity and their incorporation into overall drinking patterns. We aimed to (1) compare purchases containing only no/lo drinks, only alcoholic drinks or both, over time between 2018 and 2023; (2) identify subgroups with distinct purchasing patterns in 2023; and (3) describe sociodemographic differences between these subgroups.

Design

Latent profile analysis of cross-sectional household purchasing data.

Setting

Great Britain, 2018 and 2023.

Participants

Nationally representative samples of 30 401 (2018) and 28 254 (2023) households. 4975 households purchasing no/lo drinks in 2023 were included in the latent profile analysis.

Measurements

Data included off-trade (i.e. shop) purchasing occasions categorised into no/lo-only, alcohol-only or no/lo alongside alcohol. Household characteristics were purchasing frequency, standard servings of no/lo drinks per adult, alcohol risk levels based on weekly units of alcohol purchased per adult (non-drinker: 0 units; low-risk: ≤14 units; increasing risk: >14- ≤ 35 units; high-risk: >35 units; 1 unit = 8 g alcohol), age, social class, region and ethnicity.

Findings

From 2018 to 2023, the proportion of purchasing occasions that were alcohol-only fell from 97% [95% confidence interval (CI) = 97%–97%] to 95% (95% CI = 95%–95%), while no/lo-only purchases rose from 1.4% (95% CI = 1.3%–1.4%) to 2.7% (95% CI = 2.7%–2.8%) and no/lo alongside alcohol purchases rose from 1.2% (95% CI = 1.2%–1.2%) to 1.9% (95% CI = 1.9%–2.0%). In 2023, no/lo-only purchases were smaller (median = 6.9 no/lo servings) than no/lo alongside alcohol purchases (median = 6.5 plus 24.5 alcohol units) and alcohol-only purchases (median = 24.6 units). No/lo-only purchases occurred earlier in the week, no/lo alongside alcohol purchases peaked on Fridays and Saturdays.

Latent profile analysis identified three classes: no/lo triers (53%) averaged 2.1 no/lo servings per adult annually with 95% purchasing no or low-risk levels of alcohol; occasional purchasers (34%) averaged 7.5 servings with 20% purchasing alcohol at increasing or high-risk levels; dual purchasers (13%) averaged 37.8 servings with 39% purchasing alcohol at increasing or high-risk levels. Dual purchasers and occasional purchasers were more likely to be older [60% (P < 0.001) and 54% (P = 0.010) aged ≤55 years, respectively] and white [both 97% (P = 0.014 and P = 0.0074, respectively)] compared with no/lo triers (49% aged ≤55 years, 94% white).

Conclusions

In Great Britain, most households that purchase no/lo drinks appear to do so infrequently and purchase alcohol at low-risk levels; however, a smaller group of older, higher-risk households purchase no/lo drinks more frequently.

Overdose prevention site closure: A reply to Day et al.

Wed, 22 Apr 2026 04:39:13 -0700

Addiction, EarlyView.

Longitudinal associations between substance use problem severity and relative harm perceptions of e‐cigarettes compared with cigarettes: Results from the United States Population Assessment of Tobacco and Health study (2013–2023)

Olufemi Erinoso, Katherine East, Joanna Streck, Karin Kasza, Andrew Hyland — Wed, 22 Apr 2026 02:08:06 -0700

Abstract

Aims

This study examines, among adults who smoke: (1) the association between the harm perception of e-cigarettes relative to cigarettes and substance use problem (SUP) severity, (2) whether changes in SUP severity over time are associated with changes in harm perceptions of e-cigarettes relative to cigarettes and (3) whether associations between harm perceptions and vaping initiation are moderated by SUP.

Design

Longitudinal study.

Setting

The study setting was the United States (US) with data from the Population Assessment of Tobacco and Health (PATH) study waves 1–7 collected between 2013 and 2023.

Participants

The study population comprised non-institutionalized US adults (18+) who smoked cigarettes in the past month.

Measurements

The primary predictor for aims 1 and 2 was SUP severity. The outcomes at follow-up were: (1) relative harm perception of vaping compared with cigarette smoking [less harmful (accurate) versus more/same harm (inaccurate)], (2) change in SUP status (from no/low at baseline wave to moderate or high severity at follow-up) and change in relative harm perceptions (from inaccurate at baseline to accurate at follow-up). For aim 3, the primary predictor was relative harm perception, the outcome was nicotine vaping initiation and SUP was examined as a moderator.

Findings

A higher proportion and odds of respondents with high SUP (versus no/low SUP) had accurate harm perceptions [32.1% versus 28.5%; adjusted odds ratio (aOR) = 1.20; 95% confidence interval (CI) = 1.07–1.33]. Among individuals with no/low SUP at baseline with inaccurate perceptions, transitioning to high SUP at follow-up was associated with higher odds of developing accurate harm perceptions (aOR = 1.63; 95% CI = 1.19–2.25). Among those who smoked but had no prior history of vaping, at baseline transitioning from inaccurate to accurate harm perception at follow-up was associated with higher odds of vaping initiation (aOR = 2.08; 95% CI = 1.33–3.25).

Conclusion

People who smoke and have high substance use problem severity appear to perceive vaping as less harmful than cigarette smoking. Notably, among those who smoke but have never vaped, transitioning from inaccurate to accurate perceptions was associated with vaping initiation.

Patient‐reported outcomes for monitoring substance use treatment: A systematic review of single‐item measures

Wed, 22 Apr 2026 01:45:27 -0700

Abstract

Background and aims

Measurement-based care (MBC) is a structured approach using standardized, repeated assessments to monitor treatment progress and guide clinical decision-making. MBC improves outcomes for substance use treatment but can be time consuming due in part to lengthy assessment tools. Single-item, patient-reported outcome measures (PROMs) offer a more acceptable alternative for routine monitoring, yet their psychometric properties have not been systematically evaluated. We sought to identify constructs assessed by single-item PROMs in substance use treatment and critically appraise their validity, reliability and overall quality using standardized criteria.

Methods

We conducted a systematic review following COSMIN and PRISMA guidelines. MEDLINE, Embase and PsycINFO were searched from January 2005 to August 2025 for studies evaluating single-item PROMs in adults with substance use. We assessed psychometric properties, including content validity, test–retest reliability, construct validity, responsiveness and predictive validity using COSMIN criteria. Quality of evidence was assessed using a modified GRADE approach.

Results

Of 4722 records screened, 35 studies met inclusion criteria, evaluating 68 single-item PROMs across 9 clinical constructs for more than 50 000 participants. Fifteen studies achieved an overall rating of sufficient measure properties and moderate-or-above level of evidence rating across domains. Test–retest reliability ranged approximately from Intraclass Correlation Coefficient = 0.60–0.85; construct validity correlations approximately ranged r = 0.11–0.98. Predictive validity was strong for several measures, with odds ratios up to 7.3 for treatment readiness. Measures assessing craving, treatment readiness and self-efficacy demonstrated the most robust evidence and, in some cases, outperformed multi-item scales. However, over half of measures lacked empirically validated thresholds and responsiveness to change analyses, limiting clinical interpretability and treatment monitoring.

Conclusions

Single-item patient-reported outcome measures (PROMs) are pragmatic tools for implementing measurement-based care in substance use treatment, offering strong implementation feasibility and, in some cases, predictive performance comparable to longer instruments. PROMs lacking validated thresholds or responsiveness may be best used as complementary tools, whereas those with strong evidence and thresholds can support primary monitoring.

Association between state‐level kratom regulations and poison center‐reported severe medical outcomes and healthcare use: A United States national analysis

Grant Comstock, Anthony P. Gulotta, Lisa E. Rein, Ryan Feldman — Tue, 21 Apr 2026 22:01:27 -0700

Abstract

Background and aims

Kratom use in the United States (US) has increased. Kratom is not federally scheduled; regulation is heterogenous and determined at the state level. Strategies include no regulation, bans and kratom consumer protection acts (KCPA) such as age limits, product purity or labeling requirements. Public health data informing these policies remain limited. This study aimed to compare rates of poison center (PC) reported kratom exposures, including those associated with severe medical outcomes and healthcare use, across US states with differing regulatory frameworks, and to characterize national trends in kratom exposures over time.

Design

Retrospective observational study of kratom exposures reported to the National Poison Data System from 2010 to 2023.

Setting

All 50 US states and the District of Columbia.

Participants

A total of 8919 kratom-related exposures were reported to PCs during the study period, including 5452 single-substance exposures (61%). Most cases involved adult males (69%), aged ≥18 years (8133; 91%).

Measurements

States were classified by kratom regulatory status into four categories: unrestricted (no regulations), KCPA, local restrictions (KCPA in 1 or more county, but no state regulation) or banned (retail sale illegal). The primary outcome was the incidence of severe medical outcomes defined as exposures coded by America's Poison Centers criteria as major effect (life-threatening or resulting in significant residual disability) or death. Secondary outcomes included rates of exposure, hospitalization and healthcare use (defined as hospital admission or evaluation in an emergency department, urgent care or primary care).

Findings

Kratom exposures increased from 19 cases in 2010 to 1242 cases in 2023 [incidence rate ratio (IRR) = 69.0 compared with 2010; 95% confidence interval (CI) = 39.6–120; P < 0.001]. Severe medical outcomes increased from zero cases in 2010 to 158 cases in 2023; 2012 was the first year in which a severe outcome was reported (2023 IRR = 56.9 vs 2012; 95% CI = 14.7–221; P < 0.001). Overall, 13% of kratom exposures resulted in a severe medical outcome. Compared with states where kratom was banned, statistically significantly higher rates of exposures (IRR = 2.49; 95% CI = 1.89–3.28), severe medical outcomes (IRR = 3.19; 95% CI = 1.78–5.70), healthcare use (IRR = 2.44; 95% CI = 1.66–3.60) and hospitalization (IRR = 2.45; 95% CI = 1.81–3.30, P < 0.001) occurred (all P < 0.001). No statistically significant differences were identified between other regulatory categories.

Conclusion

Kratom exposures and severe medical outcomes reported to United States poison centers are increasing nationally, though states with bans in place have experienced less pronounced increases.