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Beyond Buprenorphine in the ED: Leveraging Lessons From 10 Years of Implementation (1/28/25)

By Nikki Bozinoff, MD, MSc, Elizabeth Schoenfeld, MD, MS, Csilla Kalocsai, MPhil, PhD 

The opioid toxicity crisis remains an urgent public health priority across the US and Canada. Since the seminal randomized controlled trial published in 2015 found that buprenorphine initiation in the emergency department (ED) was superior compared with referral to treatment alone, buprenorphine initiation in the ED has been hailed as an important mechanism for addressing the overdose crisis. However, now, nearly 10 years after the initial publication, the use of medications for opioid use disorder following an ED visit for overdose remains low, with only 3–15% of individuals filling a prescription across diverse jurisdictions. We recently published a scoping review in  , in which we wedded a popular implementation science framework, the Consolidated Framework for Implementation Research, with critical theory to try to untangle the complex web of factors that facilitate and challenge buprenorphine induction in the ED, including the power structures that may undergird the implementation gap. We reflect on the tremendous scholarly and human resource effort to implement buprenorphine in the ED and try to unpack its implications for addiction medicine. 

New Guideline on Benzodiazepine Tapering (3/4/25)

By Emily Brunner, MD, DFASAM, Chwen-Yuen A. Chen, MD, FACP, FASAM, Chinyere Ogbonna, MD, MPH, Tricia Wright, MD, MS, FACOG, DFASAM 

This week ASAM released the new . This guideline was developed to help clinicians determine when the risks of continued BZD prescribing outweigh the benefits for a given patient and how to safely taper the medication when indicated. 

Existing guidelines generally recommend limiting duration of BZD use to 2-4 weeks (except for limited conditions such as severe treatment-resistant generalized anxiety disorder, complex seizure disorders, spasticity, and sleep disorders involving abnormal movements). However, long-term BZD prescribing remains prevalent. 

The challenges of BZD tapering are not specific to addiction medicine. Nearly all patients who take BZD regularly for more than a month will develop physical dependence, while only 1.5% will develop a BZD use disorder. As such, the Guideline is applicable to diverse clinical specialties and was developed by a coalition of medical and professional societies representing psychiatrists, neurologists, family practice providers, addiction medicine specialists, geriatricians, obstetricians, medical toxicologists, psychiatric pharmacists, and advanced practice providers, with funding provided by the US Food and Drug Administration (FDA). In performing a rigorous, systematic review of the evidence around tapering BZD, the guideline development committee was surprised by the paucity of research given that the need for BZD tapering is a relatively common clinical situation. 

Advancing Reduction of Drug Use as an Endpoint in Addiction Treatment Trials (3/18/25) 

By Nora D. Volkow, Director, National Institute on Drug Abuse 

For many people trying to recover from a substance use disorder, perhaps for the majority, abstinence may be the most appropriate treatment objective. But complete abstinence is sometimes not achievable, even in the long-term, and there is a need for new treatment approaches that recognize the clinical value of reduced use. 

According to a recently published analysis of data from the 2022 National Survey on Drug Use and Health, two thirds (65.2 percent) of adults in self-identified recovery used alcohol or other drugs in the past month. There is increasing scientific evidence to support the clinical benefits of reduced substance use and its viability as a path to recovery for some patients. Reducing drug use has clear public health benefits, including reducing overdoses, reducing infectious disease transmission, and reducing automobile accidents and emergency department visits, not to mention potentially reducing adverse health effects such as cancer and other diseases associated with tobacco or alcohol.  

The FDA has historically favored abstinence as the endpoint in trials to develop medications for substance use disorders. Abstinence has been evaluated using absence of positive urine drug tests, absence of self-reported drug use, and regularly attending sessions where drug use is assessed. But abstinence is a high bar comparable to requiring that an antidepressant produce complete remission of depression or that an analgesic completely eliminate pain. Recognizing this limitation, the FDA encourages developers of opioid and stimulant use disorder medications to discuss with the FDA alternative approaches to measure changes in drug use patterns. 

Federal Policymakers Should Read the Drug Policy Research They’ve Funded (7/8/25)

By Barbara “Basia” Andraka-Christou, JD, PhD 

The federal government recently reported a stunning  in drug overdose deaths. It’s a positive omen, but it risks lulling policymakers into a false sense of accomplishment when more work must be done. Let’s not forget that overdose deaths are still unacceptably high, with tens of thousands of Americans dying each year and millions more needing evidence-based treatments. While we need further federal action to solve this crisis, not just any demand- or supply-side policies will work—they must be smart policies, informed by evidence. 

Fortunately, federal policymakers need not fly blindly. The federal government has already funded millions of dollars in high-quality research to study the effects of different policies related to addiction and overdose. Unfortunately, policymakers sometimes ignore the very studies they funded. Imagine any private sector, multitrillion dollar company paying some of the best analysts to study the effects of corporate policies but then failing to read the findings. Indeed, it is wasteful for the government to ignore observations from the very studies it has funded. Below are key findings of several publicly funded studies that must be considered as the current administration and Congress seek to decrease overdose deaths. 

Reconceptualizing Recovery: Findings from the National Survey on Drug Use and Health (8/5/25)

By Emily Pasman, PhD, LMSW 

With helpful feedback from Tess K. Drazdowski, PhD, Rebecca J. Evans-Polce, PhD, Ty S. Schepis, PhD, Curtiss W. Engstrom, MS, Vita V. McCabe, MD, and Sean Esteban McCabe, PhD 

Of the estimated 48.5 million Americans with a past-year substance use disorder (SUD), many will eventually seek recovery. Broadly, recovery is a process through which people with SUDs achieve long-term health and wellness. While various definitions of recovery have been proposed, most center around elements of SUD symptom reduction and improved functioning across life domains, rather than substance use cessation. In this way, recovery may involve complete abstinence, reduction or moderation of use to a non-problematic level, or substitution of one drug with another that is perceived to be less harmful.   

Indeed, a large body of research shows abstinence is not necessary for positive outcomes. For example, data from Project MATCH indicate some people with alcohol use disorder can reduce their use and sustain nonhazardous levels of drinking for up to 10 years post-treatment. A systematic review of cannabis use among people receiving medications for opioid use disorder concluded cannabis use did not negatively impact treatment outcomes. Further, people tend to be more successful in treatment when they are able to set their own goals, and when their goals are in alignment with those of their providers. 

One of These Things Is Not Like the Others (8/12/25) 

By Stephen A. Martin, MD, EdM, FAAFP, FASAM 

This guest editorial is part one of a two-part series on drug testing. 

Over the past decade, addiction practice in America has been slowly evolving from an abstinence-based to a low-threshold model. For opioid use disorder (OUD), low-threshold models deliberately make it easy to start and continue life-saving buprenorphine or methadone. 

Yet we continue to drug test in nearly the same ways as before, seemingly oblivious to the internal inconsistency embedded in this practice. Drug testing, derived from an abstinence-based model, is poisoning the well of low-threshold practice.  

How we got here isn’t a pretty story, and an understanding of contemporary care requires historical inquiry, skill in clinical reasoning, and an awareness of one of medicine’s tragic flaws: hubris. Below is a short summary, hewing closely to the original sources and framed as a set of rhetorical questions.  

A Reality Check (8/19/25)

By R. Corey Waller, MD, MS, FACEP, DFASAM 

This guest editorial is part two of a two-part series on drug testing. 

In addiction medicine, we use controlled substances to treat patients who have an addiction to controlled substances. This is arguably the highest-risk outpatient treatment that exists for medical providers. We are overseen and monitored by the Centers for Medicare and Medicaid Services (CMS), the Drug Enforcement Administration (DEA), state licensing boards, and local law enforcement. Each of these entities has policies that mandate the efforts we must undertake to ensure the safety of the patient, household, and broader community. Along with this is a reality that a large portion of addiction care is delivered by non-specialist providers who need as much information as possible to create an environment of safety for both their patients and themselves. As medical professionals, it is our duty to use objective information to guide the care of the patients we treat. Currently, the only true objective test we have in addiction treatment is a toxicology test. Given this, I argue that the issue is not the toxicology test itself, but rather the lack of knowledge around how to use and interpret it.  

A few guiding scientific principles  

• A test for something (lab, radiology, etc.) is not to be confused with the treatment itself. For example, a positive troponin level doesn’t change the outcome of a patient with chest pain; rather, it is the reaction to this lab result and the associated clinical factors that are responsible for the patient’s outcome.  

• Stigma is not a reason to disregard pertinent clinical information. If this were the case, we would have never tested for HIV in the 90s.  

• A lack of knowledge about interpreting a clinical test does not excuse avoiding it. Train providers to interpret the test correctly.  

Gambling Disorder in the Age of Mobile Sports Betting (10/21/25) 

By Nora D. Volkow, Director, National Institute on Drug Abuse 

Online gambling is a rapidly growing industry all over the world, affecting both adults and youth. Sports betting is now legal in 38 US states and the District of Columbia, and in 26 states, a person can now make a sports wager on the same device they use to text their therapist or check their social media feeds.  

Early data from problem-gambling helplines and state prevalence surveys suggest an increase in both gambling participation and help-seeking, with a disproportionate rise in jurisdictions that permit online betting. This circumstance presents a challenge—and opportunity—for health care in general and addiction treatment in particular. By providing evidence-supported interventions for prevention and treatment, practitioners can help ensure that the rapid growth of mobile betting is matched by an equally rapid, equally sophisticated public-health response.  

Contingency Management Saves Lives: From Evidence to Action (12/2/25)

By Lara Coughlin, PhD, and Allison Lin, MD, DFASAM 

With helpful feedback from Devin C. Tomlinson, PhD, Lan Zhang, PhD, H. Myra Kim, ScD, MPH, Gabriela Khazanov, PhD, James R. McKay, PhD, and Dominick DePhilippis, PhD  

For decades, contingency management (CM) has been the gold standard behavioral treatment for stimulant use disorder (StUD). More than 100 clinical trials show that CM consistently reduces stimulant use. Yet until now, there has been little real-world evidence that  CM improves the outcome that matters most: survival. Our recent study of Veterans Health Administration patients provides the first evidence that CM  is associated with reduced mortality among people with  StUD. Veterans who received CM were 41% less likely to die in the year after treatment initiation compared to matched peers who did not. In a moment when stimulant-related deaths are surging nationwide, this is powerful confirmation that CM is not only effective—it is lifesaving.     

Medicaid Unwinding May Have Substantially Disrupted Buprenorphine Treatment (12/9/25)

By Rachel Landis, PhD, MPP, and Bradley D. Stein, MD, PhD 

The opioid crisis remains one of the most pressing public health emergencies facing the United States. A 2023 KFF poll found that nearly one-third of adults reported that they or a family member had experienced an opioid addiction. In the same year, about 5.7 million Americans were diagnosed with an opioid use disorder (OUD), a chronic medical condition characterized by persistent use of opioids despite harmful consequences, including overdose and death. Nearly 80,000 people died from opioid overdose in 2023—almost 10 times the number of deaths in 1999. 

Unsurprisingly, OUD prevalence varies substantially across population subgroups, and low-income individuals with Medicaid insurance are among the hardest hit. Indeed, Medicaid provided coverage to 47% of nonelderly adults with OUD in 2023 and paid for medication for opioid use disorder (MOUD) treatment for 56% of those receiving it. MOUD, including buprenorphine and methadone, is the gold standard of OUD care, dramatically increasing treatment retention and reducing the risk of overdose and death.