The ASAM Weekly for July 14, 2026

Few patients with opioid use disorder (OUD) receive medications for OUD (MOUD), such as buprenorphine. Given that many patients, particularly those in rural communities, do not live near a clinician who prescribes MOUD, telemedicine could increase MOUD access. However, clinicians and policymakers are concerned about the quality of the virtual-only model. This study compared the care provided by virtual-only versus traditional clinicians. The authors found few substantive differences in who used virtual-only care. For example, patients initiating buprenorphine with virtual-only versus traditional clinicians were equally likely to live in urban areas. Patients initiating buprenorphine with virtual-only clinicians had more visits in the 6 months after the initiation and were more likely to be on buprenorphine at 6 months, but had fewer days of continuous buprenorphine treatment. These results can inform ongoing debates about the strengths and weaknesses of virtual-only OUD care.

This is a cross-sectional analysis of Medicare-enrolled opioid treatment programs (OTPs) in June 2025, as per the Centers for Medicare & Medicaid Services database. For each enrolled OTP, the county was classified as rural or urban based on Urban Influence Codes. Overall, 26.1% of the counties had a Medicare-enrolled OTP; however, there were significant differences between urban and rural counties: 46% of urban counties had an enrolled OTP, as compared to only 6.9% of rural counties. Urban areas also had a higher per capita availability of OTPs. There were additional regional variations, with the West North Central and West South Central Census Divisions having the fewest Medicare-enrolled OTPs.

This is a cross-sectional study of 42,307 fentanyl-positive urine drug tests from March 2023 to September 2025. Samples were collected by a specialty pharmacy serving a number of clinical settings, and only samples that were also tested for xylazine were included. Samples were from a majority male (57.52%) population, with the most common age range from 26–35 (36.83%). Samples from two different regions (western and eastern states) were included, and the relative concentration of xylazine by time and region was calculated. The percentage of xylazine-positive samples was higher in eastern compared to western states; however, both regions experienced a peak in xylazine positivity in summer 2024. Xylazine concentration was consistently higher in eastern states as well; however, both regions experienced a similar decline throughout the study period. The odds of xylazine detection also increased with fentanyl concentration; for every 10-fold increase in fentanyl concentration, the odds of xylazine detection increased 55%.

Co-occurring cocaine use disorder (CUD) and opioid use disorder (OUD) is not uncommon and while interventions like contingency management (CM) and cognitive behavioral therapy (CBT) are effective for CUD they may be difficult to implement in methadone treatment programs. To better understand patient perspectives and motivations, researchers conducted a qualitative study alongside a randomized controlled trial of a digital behavioral intervention. They identified a few themes in this study, including that ongoing cocaine use while on methadone is motivated by emotional distress and persistent cravings, and in response to environmental triggers. Researchers also found that while opioid use decreased after starting treatment, cocaine use may increase. Both external (ie, family support) and internal (ie, future-oriented goals) supports facilitate treatment engagement.

This study examined the effect of substance use disorders (SUDs) on mortality from COVID infection. Data were obtained from the National COVID Cohort Collaborative which contained electronic health record data from 85 US health care organizations. A total of 3,435,480 adults with COVID were included of which 11.8% had a pre-existing SUD. Having an SUD more than doubled the odds of mortality from COVID (aOR=2.4). The specific SUDs, their prevalence among the COVID patients, and odds of mortality were: alcohol 2.5%, aOR=2.6; opioids 1.4%, aOR=2.5; cocaine 1.2%, aOR=2.1; tobacco 8.8%, aOR=1.8; and cannabis 1.7%, aOR=1.6. The authors caution that the excess mortality associated with SUDs is not simply due to the physiologic effect of the substance but also reflects medical comorbidities as well as social determinants of health (housing, income, access to medical care, etc). Nevertheless, SUDs are a useful marker for increased risk from respiratory infections.

This study of pediatric opiate poisoning compared intranasal (IN) and intravenous (IV) naloxone administration. The study included 39 children presenting unconscious, with respiratory depression and miosis. They were randomized to receive naloxone either IN (1.26 mg in 0.1 ml) or IV (0.8 mg in 2 ml). The measured outcome was time from the order for naloxone to the return of respirations; this included the time to obtain the medication, and for the IV group the time to obtain IV access. The median time for the IV group was 65 seconds and for the IN group, 24 seconds (p=.001). The time from the order to administration of naloxone was significantly shorter for the IN group. The authors were surprised that the time from administration to clinical response was similar: 10 seconds for IV and 15 seconds for IN. They speculate that IN naloxone could access the brain via direct olfactory pathways.

This PRISMA-compliant systematic review and meta-analysis sought to quantify the prevalence of cannabis use (CU) and cannabis use disorders (CUD) in early-onset psychosis (EOP; <18 years) and examine their correlates and clinical and functional impact. The authors found that CU and CUD are common in EOP and relate to clinical presentation. Screening and integrated substance use care should be embedded in primary care and clinical settings. Further longitudinal studies and randomized clinical trials to evaluate the efficacy of interventions to reduce CU and CUD are needed.