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The ASAM Weekly for October 20, 2026
A Necessary Distinction
By Jessica Gregg, MD, PhD, FASAM
Contributing Editor
Harm reduction is under siege. Just over a year ago, the President issued the executive order, “Ending Crime and Disorder on America’s Streets,” in which he asserted that “so-called ‘harm reduction’” merely facilitates illegal drug use. In August, SAMHSA released a “Best Practices Toolkit: Addressing Homelessness and Addiction through ‘Treatment First’” that contains no mention of harm reduction, effectively erasing it from the recommended continuum of care. Last month, The Atlantic published a widely circulated article about the “montage of human despair” caused by harm reduction efforts among the unsheltered homeless in “The Cities That Said Yes to Drugs.”
It is nothing new for harm reduction efforts to meet resistance, despite robust evidence of their effectiveness. But the current backlash is, I think, different. The executive order, the Atlantic article, and the erasure of harm reduction language from SAMHSA’s toolkit all take as their point of departure the spread of unsheltered homelessness in US cities; they conflate harm reduction with perceived support for large homeless encampments and suggest that problems associated with those encampments demonstrate the failure of harm reduction itself.
I believe that conflation is a mistake, and a consequential one.
Behavioral Addictions Volume of The ASAM Criteria, 4th Edition
Now through November 20, the American Society of Addiction Medicine (ASAM) is seeking public comment on a draft Framework for the Behavioral Addictions Volume of the 4th Edition of The ASAM Criteria®.
For more information and instructions to review, please click here.
This modeling study developed a microsimulation model, the Multimorbidity model to Reduce Infections Associated with Drug use (MYRIAD). Key clinical outcomes and costs were projected from 2025-2034 in the US, including new HIV and HCV cases, hospitalizations for severe injection-related infections, and deaths from drug overdose and injection-related infections. For 3.3 million people who inject drugs over 10 years, the model predicted 487,249 deaths, 29,715 new HIV infections, 218,186 new HCV infections/reinfections, and 1.7 million hospitalizations related to injection drug use, with a projected health care cost of $565 billion.
This study surveyed (n=98) and interviewed (n=16) patients receiving methadone at 2 opioid treatment programs (OTPs) about difficulties with the OTPs. Travel for daily observed dosing was a problem for many. Most drove themselves (55%) or were driven by others (21%), 12% used public transportation, and 6% used medical transport. Patients noted problems with travel time (eg, 1.5 hours daily, 6 days/week) and cost of gas. OTP hours (typically 5:30 AM to 2:30 PM) conflicted with job and child care obligations. Long and unpredictable wait times (up to an hour) disrupted daily schedules. Patients also noted that OTP visits daily brought them in contact with some individuals who were using and selling drugs, risking return to use. The authors highlighted the Modernizing Opioid Treatment Access Act which would permit low-barrier access to methadone at pharmacies and addiction specialists.
This cross-sectional study of the 2021-2023 Medical Expenditure Panel Survey examined US mental health and substance use disorder expenditures in 2021-2023, and how they were distributed across disorders, populations, and services. Researchers found that annualized mental health care expenditures totaled $174 billion, representing 7% of all medical expenditures. Mood and anxiety disorders accounted for the largest aggregate expenditures, while expenditures per treated individual were highest for substance use disorders, schizophrenia, and bipolar disorder; ambulatory care accounted for most spending. Mental health expenditures vary widely across disorders, but they remain low relative to the societal burden of mental disorders.
This cohort study of 209,698 patients with diabetes in Korea assessed if smoking cessation affected the risk of incident diabetic microvascular complications in patients with type 2 diabetes. Researchers found that smoking cessation for 8 or more years was associated with significantly lower risk of overall microvascular complications and diabetic nephropathy compared with continuous smokers, and cessation for 6 to 7 years was associated with a significantly lower risk of diabetic neuropathy. Thus, long-term smoking cessation was associated with a progressive reduction in the risk of diabetic microvascular complications.
Medetomidine as an adulterant is pervasive in Philadelphia, found in over 90% of tested supply, and has been detected in over 26 states. Medetomidine is a potent alpha-2 receptor that has a profound rapid withdrawal syndrome including hemodynamic instability, often requiring ICU admission to manage. Researchers developed a protocol to manage these patients in an intermediate care unit (IMCU), including an order set for dexmedetomidine infusions, which is described along with outcomes. Over the course of the study 487 patients were admitted, with 449 following the protocol. Approximately half of patients required ICU admission, with half of those occurring prior to transfer to IMCU. The researchers note this protocol could serve well for less acute patients to avoid ICU and for ICU downgrades as patients stabilize.
This is a retrospective cohort study using the TriNetX research network database, a multicenter federated health research network of more than 120 health care organizations in 19 countries, including data from approximately 275 million patients. The study evaluated patients with OUD who were prescribed buprenorphine or methadone (n=162,558), with primary endpoints of incidence of metabolic outcomes, serious infectious complications, medical care utilization, and addiction-related and mental health outcomes. Buprenorphine was prescribed about twice as often as methadone and was associated with lower risks of type 2 diabetes, metabolic syndrome, ischemic stroke, and opioid-related overdoses. Buprenorphine was associated with higher rates of OUD remission; it was also associated with higher risks of alcohol use disorder, anxiety disorders, and major depression.
Journal of Addiction Medicine Editorial Fellowship Program—Application Open!
The Journal of Addiction Medicine (JAM) seeks 3 Editorial Fellows to serve a 2-year term. Applicants should have at least 2 years of addiction research experience; hold an MD, DO, PhD, DSc, or PsyD degree (or equivalent); have completed clinical specialty training; and hold faculty positions at the instructor or assistant professor level or an equivalent junior faculty level.
Fellows will commit to 3-4 hours a week and participate in weekly 30-minute conference calls with the editorial team. Deadline to apply*: October 31, 2026
*To Apply:
ASAM Members: log into the portal, click Forms, Online Forms, and select Editorial Fellows Application.
Non-members: Set up an account, then follow the instructions above.
This study examined the frequency of alcoholic ketoacidosis (AKA) in patients seen in the ED for diagnoses of alcohol intoxication or withdrawal. Researchers identified 905 patients, of whom 78% had alcohol intoxication and 22% alcohol withdrawal. Only 39% had a urinalysis, and 43% of these were positive for ketones. The authors note that ketonuria can be negative even when serum ketones are present. An anion gap metabolic acidosis (AGMA) was present in 26% of patients. Both ketonuria and AGMA were present in 11%. Even with severe acidosis, AKA was diagnosed less than half the time. Patients with withdrawal were more likely to have AGMA than those with intoxication (44% vs 21%, p<.001). The authors estimated that 11%-26% of ED patients with alcohol-related diagnoses had AKA and that it was infrequently diagnosed.
Nearly half of patients in treatment for opioid use disorder (OUD) have chronic pain, but pain in this population is often undertreated. Researchers interviewed patients with co-occurring OUD and chronic pain and identified 3 primary themes as barriers to treatment. The first theme was a mismatch between the health system and patients’ lives, including financial and logistical (time and travel) barriers affecting access and patient life instability, including mental health concerns, that limited access. The second theme focused on pain care, with patients facing stigma and mistrust in those practices. The third theme focused on medication for opioid use disorder (MOUD) treatment settings where pain care was not a priority and responsibility for managing pain was disallowed. Researchers note that addressing these challenges requires a broader health care system approach.
- Why ketamine immobilizes some usersThe New York Times
- The liability behind ketamine’s promiseMedPage Today
- Meth use disorder may benefit from accelerated transcranial magnetic stimulationMedPage Today
- Contingency management can treat stimulant addiction. So why isn’t it used in Canada? 🔓Canadian Affairs
- It’s time to deliver safe and effective psychedelic medicine 🔓The Hill
- CVS agrees to pay $315 million to settle Justice Department case over opioid prescriptions 🔓The Associated Press