Prevalence of Substance Use Disorder Higher Among Some Cancer Survivors

Heavy alcohol use and tobacco use are known to increase the risk of some cancers, but less is known of what happens to people who have a substance use problem after surviving cancer. A report in JAMA Oncology now suggests that substance use disorder is more prevalent among survivors of head and neck cancer, esophageal and gastric cancer, cervical cancer, and melanoma than survivors of breast, prostate, and colon cancers.

“Our findings underscore the need to understand and address the needs of cancer survivors with comorbid [substance use disorder],” wrote Katie F. Jones, Ph.D., of the VA Boston Healthcare System and colleagues. “Our results also highlight certain populations of cancer survivors who would likely benefit the most from such interventions based on their higher prevalence of SUD, including those with a lifetime history of and those with recently diagnosed cervical and head and neck cancers.”

For the cross-sectional study of adult cancer survivors, Jones and colleagues analyzed data collected between 2015 and 2020 as part of the annual National Survey on Drug Use and Health (NSDUH). The researchers defined substance use disorder (SUD) as “meeting at least 1 of 4 DSM-IV criteria for abuse or at least 3 of 6 DSM-IV criteria for dependence.” The researchers calculated the weighted population prevalence of SUD by cancer type.

A total of 6,101 adult cancer survivors (about 57% aged 65 and older; 62% female) were included in the analysis. Across cancers, the weighted prevalence of active SUD was 3.83%, and alcohol use disorder was the most common SUD, with a weighted prevalence of 2.78%. The prevalence of SUD was higher among survivors of the following:

• Esophageal and gastric cancer (9.42%)
• Head and neck cancer (9.36%)
• Cervical cancer (6.24%)
• Melanoma (6.20%)

In a secondary analysis of 1,437 survivors who were diagnosed with cancer within 12 months of participating in the NSDUH, the overall prevalence of SUD was similar as the main cohort (3.81%); however, the prevalence of SUD among the survivors of head and neck cancer and cervical cancer was 18.73% and 15.70%, respectively.

The authors highlighted several limitations of the study—for instance, the overall SUD prevalence in cancer survivors was lower than previous reports of SUD prevalence in the general population; additionally, the authors noted that they did not have access to information about the prognosis of those who had been diagnosed with cancer.

“[T]he findings of the present study underscore the need for research on models of care that integrate addiction services and expertise into the care of cancer populations with a high prevalence of [substance use disorder] to address their complex and intersecting needs,” Jones and colleagues wrote.

For related articles, see the Psychiatric News article “Special Report: Psychiatrists Critical in Screening, Treatment of Alcohol Use Disorder.”

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Americans Agree Cigarettes Are Unsafe, Yet 21% Report Smoking Every Day

More Americans consider cigarettes to be addictive and dangerous than those who express such concerns about cannabis, alcohol, and technology. These were among the latest findings from a national APA poll released today.

“It is clear that we have gotten the message through that cigarettes are dangerous and addictive,” but more can be done to educate Americans about other potentially addictive behaviors, APA President Petros Levounis, M.D., M.A., said in a news release. “For instance, vaping is just as, if not more, addictive than cigarette smoking.”

The poll was conducted by Morning Consult between April 20 and 22 among a sample of 2,201 adults and has a margin of error of plus or minus 2 percentage points.

Most respondents reported that they believe cigarettes (87%), alcohol (84%), prescription opioids (83%), and vapes (81%) are addictive. Only 64% considered cannabis to be addictive. Further, 67% reported daily technology use, 21% reported daily cigarette use, and 13% reported daily cannabis use.

Levounis emphasized that there are safe and effective treatments available to help people with substance use disorders and behavioral addiction. “Addiction treatment works,” he said.

According to the release, APA will soon launch a public awareness initiative on addiction and substance use disorders. The focus will initially be on vaping, then turn to opioids, alcohol, and technology over the next year.

Survey respondents were split on if they consider addiction to be a result of personal weakness (47% reported that they did while 53% reported that they did not). However, 76% consider addictions to be medical disorders, 76% believe they are preventable, and 93% believe they can be treated. Additional findings from the survey include the following:

• 75% believe technology is addictive, and 65% believe it is safe.
• 71% say that if they or someone they know was struggling with an addiction, they would feel knowledgeable about ways to help.
• 58% say they have seen, read, or heard about Narcan and/or naloxone, but only 35% of adults say that, in the case of an opioid overdose, they would know where to find the life-saving medication.

“In 2022, opioids killed more than 100,000 people,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “While it is encouraging that most Americans see substance use disorder as a treatable medical condition, we can do more to ensure that more of us in our communities are aware of and can access naloxone, which saves lives.”

For related information, see the Psychiatric News alert “Americans Feel Worried About Their Safety, APA Poll Finds.”

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Psychosis Induced by Substance Use Linked to Schizophrenia

More than a quarter of people who experience substance-induced psychosis are diagnosed with schizophrenia within six years, a study in The American Journal of Psychiatry has found.

Eline B. Rognli, Ph.D., of Oslo University Hospital and colleagues analyzed data from 3,187 patients in the Norwegian Patient Registry who were between the ages of 18 and 79 and had a diagnosis of substance-induced psychosis from 2010 to 2015. The patients had a mean age of 33.6 years, and 73.5% were men. Among the patients, 14.2% had alcohol-induced psychosis, 17.6% had cannabis-induced psychosis, 22.2% had amphetamine-induced psychosis, and 38.8% had psychosis induced by multiple substances. The patients were followed from the first diagnosis of substance-induced psychosis in the observation period until a diagnosis of schizophrenia spectrum disorder or bipolar disorder, death, migration, the month they turned 80, or the end of 2015, whichever came first.

Overall, 27.6% of the patients with substance-induced psychosis transitioned to schizophrenia within six years. Men had a higher rate of transitioning to schizophrenia than women: 28.6% among men compared with 24.8% among women. The transition rate was highest for the youngest patients: 32.7% for patients aged 18 to 25 years and 32.9% for patients aged 26 to 30 years. The transition rate was highest for cannabis-induced psychosis and lowest for alcohol-induced psychosis. Among those who transitioned to schizophrenia, 56.4% did so within a year of their diagnosis of substance-induced psychosis.

The researchers also examined the relationship between substance-induced psychosis and bipolar disorder. Overall, 4.5% of patients with substance-induced psychosis transitioned to bipolar disorder within six years. Women had a higher rate of transitioning to bipolar disorder than men: 7.1% among women compared with 3.5% among men. Among those who transitioned to bipolar disorder, 52.0% did so within a year of their diagnosis of substance-induced psychosis.

“Transition rates from substance-induced psychosis to schizophrenia spectrum disorder were six times higher than transition rates to bipolar disorder. … [O]ur findings indicate that substance-induced psychosis, particularly cannabis-induced psychosis, is a major risk factor for schizophrenia, and that younger age among men and repeated emergency admissions are associated with higher risk,” the researchers wrote. “This should inform and guide how … health services provide care for individuals with substance-induced psychosis.”

For related information, see The American Journal of Psychiatry article “Prediction of Onset of Substance-Induced Psychotic Disorder and Its Progression to Schizophrenia in a Swedish National Sample.”

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AJP Editors Identify Top Studies in 2022 That May Have Significant Impact in Psychiatry

At the end of each year, members of the American Journal of Psychiatry (AJP) Editorial Board select the studies they found particularly impactful in the previous 12 months. The nine studies selected for 2022 have expanded the understanding of the impact of stress hormones on brain development, revealed new insights into how and when the brains of infants who go on to develop autism diverge from their peers, exposed the long-term cognitive effects of cannabis use, and more.

“There were outstanding papers selected this year that showcase some of the cutting-edge tools and ideas … in psychiatry,” said Ned Kalin, M.D., AJP editor-in-chief and the Hedberg Professor and Chair of Psychiatry at the University of Wisconsin School of Medicine and Public Health.

Kalin’s selection was the study that utilized brain organoids to assess how stress hormones, such as cortisol, affect brain development. “We know that early life stress is a very large risk factor for psychiatric illness later in life,” he said. “Cerebral organoids are like living test tubes that enable researchers to recreate these aspects of these early life stressors and observe how developing neurons are impacted.”

Other 2022 editors’ picks included the following:

• A clinical trial of a new protocol for transcranial magnetic stimulation that obtained impressive results in only five days for patients with treatment-resistant depression. The protocol, named the Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), was subsequently cleared for use by the FDA.
• A brain imaging study that revealed that the brains of children with autism spectrum disorder appear to diverge from other children between 6 and 12 months of age, pointing to a key period when early intervention may have a strong impact.
• A longitudinal study tracking more than 1,000 individuals from age 3 for 40 years in New Zealand that found that chronic cannabis users had more significant declines in processing speed, memory, and attention over their life than non-cannabis users. Long-term cannabis users also had greater declines in these cognitive areas compared with long-term drinkers and smokers.
• AJP Residents’ Journal editor Danielle W. Lowe, M.D., Ph.D., spotlighted two articles on transgender care from a special thematic issue in 2022 on minority mental health and the importance of respecting patient identity. The articles included a case report highlighting the impact of gender dysphoria on the development of eating disorders and a piece on improving dialogue with transgender patients to reduce discrimination and stigma.

To learn more about these and the other selected studies, see the Psychiatric News article “2022 AJP Editors’ Picks Showcase Innovation, Long-Term Studies” and the AJP article “2022 Articles of Import and Impact.”

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Pregnant Women Don’t Perceive Regular Cannabis Use to Be of Great Risk, Survey Suggests

Despite evidence to the contrary, nearly 3 of 4 pregnant women in the United States do not characterize regular cannabis use as a great risk, according to a report in the American Journal of Preventive Medicine. These findings were based on survey responses of more than 15,000 pregnant women aged 12 to 44.

While the data are still emerging, “several studies suggest that marijuana use during pregnancy could be linked to problems with attention, memory, problem-solving skills, and behavior in their children later in life,” according to the Centers for Disease Control and Prevention.

Omayma Alshaarawy, M.B.B.S., Ph.D., and Alyssa Vanderziel, M.S., of Michigan State University analyzed data collected between 2002 and 2019 from the National Survey on Drug Use and Health (NSDUH), an annual survey by the Substance Abuse and Mental Health Services Administration that asks participants about tobacco, alcohol, and drug use; mental health; and other health-related issues. The data are extrapolated to the U.S population. The analysis included the responses of 15,109 pregnant women to questions about their cannabis consumption and perception of risk of regular cannabis use.

The authors defined cannabis consumption as the use of cannabis at least once in the past 30 days. To assess perceptions of risk of cannabis use, the participants were asked “How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?”

The prevalence of prenatal cannabis use nearly doubled from 2002 to 2017, but there was no significant change in the prevalence of prenatal cannabis use between 2016-2017 (5.8%) and 2018-2019 (4.7%), Alshaarawy and Vanderziel reported. The percentage of pregnant women perceiving regular cannabis use as a great risk was about 50% from 2002 to 2007; by 2019, this percentage had dropped to 27%.

The researchers noted that because the question of risk of cannabis use was not specific to prenatal use, it is possible that the participants’ responses “might reflect perceptions of risk related to use among nonpregnant people and not necessarily related to potential harms inflicted on the pregnant mother and/or fetus.”

They concluded, “As cannabis legalization increases, public health efforts are needed to raise awareness of the possible harms associated with cannabis use.”

For related information, see the Psychiatric News article “Cannabis Use During Pregnancy on the Rise.”

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Poor Sleep Habits Linked to Binge Drinking Among Adolescents

Adolescents who prefer going to sleep later in the evening, are sleepy during the day, and sleep for shorter periods of time are more likely to participate in severe binge drinking the following year, according to a study published Tuesday in Alcoholism.

“Growing longitudinal evidence indicates that late childhood and adolescent sleep characteristics predict alcohol and cannabis use and related problems in later adolescence and young adulthood,” wrote Brant Hasler, Ph.D., of the University of Pittsburgh and colleagues. “These findings extend a growing literature supporting the relevance of sleep/circadian characteristics to risk for alcohol and cannabis use.”

Hasler and colleagues used data from six annual assessments from 801 participants enrolled in the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study. Participants, aged 12 to 21 years at baseline, were interviewed to determine past-year alcohol use, cannabis use, and severity of binge drinking. The authors defined binge drinking based on a scale determined by age, ranging from three or more drinks for participants 13 and younger, up to five or more drink for male participants 18 and older, and four or more drinks for female participants 18 and older. Participants were considered to have engaged in heavy binge drinking if they reported consuming double the initial age-based binge levels and extreme binge drinking if they consumed triple the initial levels.

As part of the NCANDA study, the participants were also asked about their sleep habits, including circadian preference (meaning what time participants prefer to wake up and go to bed), past-month sleep quality, daytime sleepiness, and what time participants typically went to bed and woke on both weekdays and weekends.

Adolescents who reported a preference for going to bed later and waking later, greater daytime sleepiness, and shorter sleep duration on both weekdays and weekends were more likely to binge drink the next year, the researchers found. Further, shorter sleep duration on weekends was the predominant predictor of future binge drinking severity when compared with all the sleep measures, with one hour less sleep on weekends resulting in 19% increased risk for severe binging the following year. Preferring a later bedtime and wake time was also associated with a higher risk of cannabis use the next year.

“Sleep is a modifiable behavior in adolescents … and, consequently, adolescent sleep may be a viable target for reducing substance use risk through, for example, policy-level changes delaying school start times,” the authors concluded.

For related information, see the Psychiatric News article “Short Sleep Duration Increases Adolescent Suicide Risk.”

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Cannabis Use May Increase Risk of Suicidality in Young Adults, Study Suggests

Cannabis use appears to be associated with an increased risk of suicidal thoughts and actions in young adults, according to a study published Tuesday in JAMA Network Open. These risks were similar regardless of whether the young adults had major depression and were more pronounced in women than men.

“Suicide is a leading cause of death among young adults in the United States, and the findings of this study offer important information that may help us reduce this risk,” said lead study author Beth Han, M.D., Ph.D., M.P.H., of the National Institute on Drug Abuse (NIDA) in a news release.

Han and colleagues analyzed data collected from 281,650 adults aged 18 to 34 years who participated in the National Survey on Drug Use and Health between 2008 and 2019. As part of the survey, participants were asked about past-year major depressive episode and suicidal ideation, plan, and attempt. They were also asked about lifetime and past-year use of tobacco, alcohol, cannabis, and cocaine, as well as sociodemographic information (including age, sex, race/ethnicity, educational attainment, college/school enrollment, employment status, family income, marital status, and health insurance). The authors used DSM-IV criteria to estimate the prevalence of past-year alcohol, cannabis, and cocaine use disorders and major depressive episode.

Past-year suicidal ideation and plan along with daily cannabis use increased among all of the sociodemographic subgroups, with the exception of daily cannabis use among current high school students, the authors reported. Past-year suicide attempts also increased among most subgroups.

“Past-year [cannabis use disorder], daily cannabis use, and nondaily cannabis use were associated with a higher prevalence of past-year suicidal ideation, plan, and attempt in both sexes,” the authors wrote. For instance, among people without a major depressive episode, about 3% of those who did not use cannabis had suicidal ideation, compared with about 7% of those with nondaily cannabis use, about 9% of those with daily cannabis use, and 14% of those with a cannabis use disorder. Similarly, among people with depression, 35% of people who did not use cannabis had suicidal ideation, compared to 44% of those with nondaily cannabis use, 53% of those with daily cannabis use, and 50% of those with a cannabis use disorder. Women who used cannabis at any frequency were more likely to have suicidal ideation or report a suicide plan or attempt than men with the same frequency of cannabis use.

“While we cannot establish that cannabis use caused the increased suicidality we observed in this study, these associations warrant further research, especially given the great burden of suicide on young adults,” said NIDA Director Nora Volkow, M.D., who is a senior author on the study. “As we better understand the relationship between cannabis use, depression, and suicidality, clinicians will be able to provide better guidance and care to patients.”

For related information, see the Psychiatric News article “Cannabis Withdrawal Syndrome Affects Nearly Half of Those Who Quit” and the American Journal of Psychiatry article “U.S. Adults With Pain, a Group Increasingly Vulnerable to Nonmedical Cannabis Use and Cannabis Use Disorder: 2001–2002 and 2012–2013.”

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Cannabis Use Before, During Pregnancy Rising, Study Finds

An analysis of medical records from pregnant women in northern California shows that cannabis use before and during pregnancy increased significantly over a nine-year period, according to a study in JAMA Network Open. The percentage of women who reported using cannabis in the year before becoming pregnant rose from 6.8% in 2009 to 12.5% in 2017, while the number of women who used cannabis while pregnant rose from nearly 2% to 3.4% during this period.

“Frequent cannabis use among pregnant women raises important public health concerns, as initial evidence suggests that heavier use might be associated with worse neonatal health outcomes,” wrote Kelly Young-Wolff, Ph.D., M.P.H., of Kaiser Permanente Research and colleagues. “Pregnant women who use cannabis more frequently during pregnancy are also more likely to use other drugs, and future research is critically needed to examine the short- and long-term health outcomes for mothers and their offspring associated specifically with daily [versus] occasional cannabis use during different time points in pregnancy.”

Young-Wolff and colleagues assessed Kaiser health records on 276,991 women who became pregnant between January 1, 2009, and December 31, 2017, and completed an assessment of their current and past cannabis use during their first prenatal visit. The final analysis included 367,403 pregnancies (75,234 women had more than one pregnancy during the study period).

The researchers found that the average number of women who reported daily, weekly, or monthly cannabis use during pregnancy or in the year prior increased between 2009 and 2017, with daily use rising the most rapidly. Between 2009 and 2017, the number of women who used cannabis daily in the year prior to pregnancy rose from 1.2% to 3.1%, while among pregnant women this number rose from 0.3% to 0.7%.

Younger women, black women, and women with lower average incomes were more likely to use cannabis before and during pregnancy.

Young-Wolff and colleagues noted that a previous analysis that confirmed prevalence of cannabis use during pregnancy using urine tests also reported increased use over time; this suggests that the current study findings are not simply the result of women being more willing to disclose their cannabis use due to wider social acceptance of the drug.

To read more about cannabis use, see the Psychiatric News article “Daily and High-Potency Use of Cannabis Linked to Psychosis.”

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Nabaximols Nasal Spray May Reduce Cannabis Use By Some Patients

A study published today in JAMA Internal Medicine reports that the cannabinoid agonist nabiximols can reduce cannabis use among people with cannabis dependence when combined with behavioral therapy. Nabiximols is a nasal spray composed of purified tetrahydrocannabinol (THC) and cannabidiol (CBD)—two of the primary active components of cannabis.

Study participants who received a combination of nabiximols and behavioral therapy reported using cannabis about 33% fewer days than those allocated to placebo and behavioral therapy, noted Nicholas Lintzeris, M.B.B.S., Ph.D., of Australia’s Drug and Alcohol Services and colleagues. “The reductions in illicit cannabis use and a safer route of administration … suggest the harm-reduction benefits of cannabinoid agonist treatment,” the authors wrote.

Lintzeris and colleagues enrolled 128 adults with cannabis dependence (as defined by the International Classification of Diseases, 10th Revision, or ICD-10) who were seeking treatment to participate in a 12-week trial. As part of the trial, the participants received either nabiximols or placebo nasal spray for daily use and were offered six individual cognitive-behavioral therapy sessions over the course of the trial. Each individual nabiximols spray contains 2.7 mg of THC and 2.5 mg of CBD, and participants could take up to 32 sprays daily.

At baseline, the participants reported using cannabis about 25 of the past 28 days. During the 12-week trial, adults in the placebo group reported significantly more days using cannabis (53 of 84 days) compared with those in the nabiximols group (35 of 84 days). Although there was no statistical difference between the groups in the number of participants who achieved cannabis abstinence (defined as at least 28 consecutive days without use), more adults in the nabiximols group were able to cut their cannabis use by 50% or more (54.1% vs. 28.9%).

The authors noted several limitations of the study, including the finding that only about half of the patients in the placebo and nabiximols groups stayed in treatment throughout the 12-week study. “Although our treatment retention of 46.9% at 12 weeks is comparable with prior randomized clinical trials of cannabinoid agonist treatment (55% at 11 weeks and 67% at 12 weeks), the limited treatment retention across these studies highlights the fact that cannabinoid agonist treatment is not effective for or acceptable to all patients,” Lintzeris and colleagues wrote. “Whereas nicotine-agonist and opioid-agonist treatments are considered frontline therapies, our findings suggest a more cautious approach for cannabinoid agonist treatment at this time.”

For related information, see the Psychiatric News article “Medications May Ease Cannabis Withdrawal But Fail to Achieve Abstinence” and the Psychiatric Services article “Thinking Carefully About Marijuana Legalization: Public Health Considerations for State Policy Makers.”

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More Pregnant Women Using Cannabis, Possibly Raising Risk of Preterm Birth, Research Shows

It’s becoming more common for pregnant women in the United States to use cannabis: Between 2002 and 2017, the prevalence of past-month cannabis use increased from 3.4% to 7.0% among pregnant women overall and from 5.7% to 12.1% during the first trimester, according to a report published today in JAMA.

These and other findings, which were based on the responses of women to the National Survey on Drug Use and Health (NSDUH), highlight “the importance of screening and interventions for cannabis use among all pregnant women,” wrote Nora Volkow, M.D., director of the National Institute on Drug Abuse, and colleagues.

As part of the NSDUH, interviewers asked women about their pregnancy status; whether they used cannabis in past month; and, if so, how often they used cannabis over the past month (daily/near daily use was defined as 20 or more days of use in the past month). Beginning in 2013, respondents reporting past-year and past-month cannabis use were also asked whether any of their cannabis use was recommended by a health care professional. Those who responded no were categorized as having “nonmedical-only cannabis use.”

Volkow and colleagues analyzed data collected from 467,100 respondents overall between 2002 and 2017. During this time, the adjusted prevalence of past-month daily/near daily cannabis use increased from 0.9% to 3.4% among pregnant women overall, including from 1.8% to 5.3% during the first trimester, from 0.6% to 2.5% during the second trimester, and from 0.5% to 2.5% during the third trimester. Most women reported their cannabis use was not recommended by a health care professional: The prevalence of past-month medical cannabis use among pregnant women aged 12 to 44 years was no more than 0.68%, the authors reported.

In a separate study, also published today in JAMA, researchers reported that women who use cannabis during pregnancy may be more likely to deliver babies preterm.

Daniel J. Corsi, Ph.D., of Ottawa Hospital Research Institute and colleagues examined data collected from 661,617 women aged 15 and older who delivered a baby in an Ontario hospital between April 2012 and December 2017. Corsi and colleagues compared information on birth outcomes of 5,639 mothers who reported use of cannabis during pregnancy with 92,873 mothers who reported no use of cannabis.

After adjustment for confounding variables, Corsi and colleagues found that there was a significant association between reported cannabis use in pregnancy and preterm birth, defined by the authors as less than 37 weeks of gestation. In contrast, there was a statistically significant protective association between reported cannabis exposure and preeclampsia and gestational diabetes, the authors observed.

“These two studies send a straightforward message: cannabis use in pregnancy is likely unsafe; with an increasing prevalence of use (presumably related to growing social acceptability and legalization in many states), its potential for harm may represent a public health problem,” Michael Silverstein, M.D., M.P.H., of Boston Medical Center and colleagues wrote in an accompanying editorial.

For related information, see the Psychiatric Services article “Thinking Carefully About Marijuana Legalization: Public Health Considerations for State Policy Makers.”

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