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The ASAM Weekly for August 26th, 2025

This Week in the ASAM Weekly 

Perceptions play a significant role in addiction. For example, a study comparing how perceived social support can vary among addictions reinforced an interesting finding—young men with gambling or gaming addiction perceive themselves to have lower social support than those with substance use disorders (PLOS One). Similarly, treatment providers are also influenced by social perceptions in health care settings. A study exploring barriers to screening for problem gambling found that the perceived approval of colleagues can be an effective motivator to talk with patients (Journal of Public Health). 

Eventually, though, perceptions must reconcile with reality. The early promise of alcohol screening and brief interventions may not withstand the realities of publication bias, regression to the mean, or natural remission (BMJ). On the other hand, some perceptions seem to persist, like the low priority that many SUD treatment facilities place on smoking cessation. The reality is that cessation significantly reduces the harms of tobacco use while also improving recovery from other SUDs (JAMA Psychiatry). 

Sometimes, there is a risk that perceptions and reality will continue to diverge. California voters overwhelmingly supported Proposition 36, which promised a tougher-on-crime approach coupled with mandated treatment. The real-world application, however, might be more like an “unfunded mandate” vulnerable to good intentions with gaps in care (The Sacramento Bee). Urine drug testing is another example that gets challenged by real-world application. Even though we’ve learned to appreciate their limit in clinical settings, these tests continue to drive many consequential decisions in the legal system (Health Affairs). 

The best perceptions, then, are those that seem to deepen with real-world application. A good example of this is buprenorphine induction. We’ve come a long way from the days of office-based monitoring, and different settings have found success with low-dose and high-dose inductions, but the challenge of buprenorphine induction remains. Now that we have an injectable-only protocol, hopefully, that challenge—and our perceptions—will soon change (JAMA Network Open).  

But further research (real-world application) is needed. 

Thanks for reading,

Nicholas Athanasiou, MD, MBA, DFASAM
Editor in Chief

with Co-Editors: Brandon Aden, MD, MPH, FASAM; John A. Fromson, MD; Sarah Messmer, MD, FASAM; Jack Woodside, MD

ASAM Releases Updated Patient Guide for Opioid Addiction Treatment

ASAM has released an updated version of its free digital resource, Opioid Addiction Treatment: A Guide for Patients, Family and Friends. This comprehensive guide now includes important updates reflecting the evolving landscape of opioid use and treatment since its original publication in 2020. 

Access the Updated Guide


Lead Story 

Injectable-Only Overlapping Buprenorphine Starting Protocol in a Low-Threshold Setting 🔓

JAMA Network Open 

Injectable-only buprenorphine protocols represent an exciting new strategy for buprenorphine initiation, particularly in the fentanyl era. In this cohort study, 95 patients with moderate to severe opioid use disorder received care in a low-threshold setting in Seattle. Of patients included in the study, 79% were experiencing homelessness or living in permanent supportive housing. Patients selected a long-acting injectable (LAI) buprenorphine initiation protocol, which included 3 escalating doses of LAI buprenorphine over 3 days, with no sublingual buprenorphine and without cessation of fentanyl/opioid use. Seventy-five percent of the patients completed the protocol, and 64% received a second monthly dose of LAI buprenorphine. 

Research and Science 

Clinical Practice Guideline: Assessment and Treatment of Adolescents and Young Adults With Substance Use Disorders and Problematic Substance Use (Excluding Tobacco) 🔓 

Journal of the American Academy of Child & Adolescent Psychiatry 

This clinical practice guideline highlights 5 empirically supported treatment suggestions for substance use disorder (SUD) and problematic substance use (PSU) in youth. Suggested safe and effective short-term treatments for SUD/PSU in adolescents and young adults include brief (1-2 session) motivational interviewing for alcohol use; non-brief (>2 sessions) motivational interviewing, family therapy, or cognitive behavioral therapy for alcohol use or disorder with or without other drug use; motivational interviewing plus cognitive behavioral therapy for illicit drug disorders; behavioral interventions for college students with problematic alcohol use; and longer-term buprenorphine treatment and slower buprenorphine taper for opioid use disorder. The Strength of Evidence (SOE) was insufficient to support suggestions or recommendations for the pharmacological or behavioral treatment of any other adolescent SUD/PSU. Despite the magnitude of the problem, there is a paucity of safe and effective treatments for adolescents and young adults with SUD/PSU, suggesting the urgent need for additional research. 

Cigarette Smoking During Recovery From Substance Use Disorders

JAMA Psychiatry

This longitudinal survey cohort study of 2,652 participants assessed if changes in cigarette smoking predict substance use disorder (SUD) recovery over time, accounting for between-person confounders. Researchers found that within-person transitions away from smoking were positively associated with SUD recovery in a nationally representative cohort; quitting smoking increased the odds of SUD recovery by 30% in fully adjusted models. Findings were robust in sensitivity analyses. These results imply that quitting smoking is linked to better SUD recovery outcomes; smoking cessation could be a tool for assisting the recovery process among the millions of US adults with a current SUD. 

Understanding barriers and motivators for problem gambling screening by professionals in healthcare and social-assistance settings🔓

Journal of Public Health

Using a mixed-methods approach, researchers surveyed and interviewed professionals who work with clients who may be at risk for gambling harms to assess intention and behavior around talking to clients about gambling. The researchers used the theory of planned behavior as a model for the study and found that perceived opinions of colleagues influenced intentions to discuss gambling, and perceived behavioral control predicted both intentions to and discussing gambling with clients. In addition, researchers identified barriers to discussion, including uncertainty or lack of knowledge about screening techniques and referral pathways.  

Perceived social support according to the type and number of addictions🔓

PLOS One

This questionnaire-based study sought to identify whether perceived social support (PSS) varies according to different types of addiction and/or the presence of multiple addictions. Participants included 5,654 young men (age 18-25) in Switzerland who completed a questionnaire that included a scale measuring for PSS as well as standardized screening tools to identify addictive behaviors (gambling and gaming) and consumption of alcohol, cannabis, and nicotine. In this sample, 24.2% met screening criteria for 1 addiction, and 9.8% met screening criteria for 2 or more addictions. Nicotine use disorder was the most prevalent substance use disorder identified at 16.7%. Gaming disorder was much more prevalent at 10.1% compared to gambling disorder at 1.1%. Results showed that young men with gambling or gaming addiction reported the lowest levels of PSS, and that rates of PSS decrease with multiple addictions in a linear fashion.

Learn More 

A Comparative Analysis of Genetic and Epigenetic Factors in METH Addiction: A Focus on SLC (SLC6A4) and COMT Genes 🔓 

Frontiers in Bioscience-Landmark 

This study reviewed 25 papers investigating the relationship between genetics and meth addiction. The COMT gene codes for an enzyme responsible for the metabolism of catecholamines such as norepinephrine and dopamine. The met/met polymorphism of the COMT gene reduces enzyme activity and reduces the risk of meth addiction (OR=-2.8) while the val/val polymorphism increases both enzyme activity and risk of meth addiction (OR=1.9). The SLC6A4 gene codes for the serotonin transporter, and the presence of the S (short) allele increased the risk of meth addiction (OR=2.3) and early-onset meth use (OR=2.1). Epigenetic modifications of these genes also influenced addiction pathways. 

Amputation trends among people who use drugs in the context of Philadelphia’s increasingly xylazine adulterated drug supply 🔓 

Drug and Alcohol Dependence 

In Philadelphia the presence of xylazine in the opioid supply has been increasing from 7% in 2017 to 34% in 2021 to 99% in 2023. This study included inpatient visits with a diagnosis of opioid related disorder at 4 Philadelphia hospitals between 2018 and 2023 (n=12,047). During this period the rate of amputations in patients with opioid related disorder increased from 0.8% in 2018 (similar to the general population) to 1.56% in 2023. Higher rates of amputation were seen in males (OR=1.7) and patients with diabetes (OR=5.3). The increasing presence of xylazine in the opioid supply was associated with a doubling of the rate of amputations.

Alcohol screening and brief intervention in clinical practice

The BMJ 

The authors of this editorial review some of the literature on alcohol screening and brief intervention (ASBI) and infer the real-world effectiveness initially indicated in early studies has not come to fruition. They suggest that ASBI mostly targets risky drinkers who have low morbidity and whose behavior often regresses to the mean and ASBI adds limited effect in this natural remission. The authors propose more benefit in screening for and early detection of higher risk patients with alcohol use disorder with the goal of earlier linkage to alcohol treatment specialists.