This Week in the ASAM Weekly

Inequality is a common thread of addiction. Socioeconomically, addiction can exacerbate poverty and homelessness, while the trauma of poverty and homelessness can increase vulnerability to addiction (Reason Foundation). There is even inequality with neurodevelopment, whether it’s the psychopathology of children exposed in utero (Drug and Alcohol Dependence) or the social-emotional blunting of cannabis use in adolescence (Forbes)—each can impact quality of life.

Oftentimes, society re-enforces inequality by criminalizing addiction. Drug use during pregnancy is by no means a good thing, but the way many states penalize it only deepens inequality of race, gender, and socioeconomic status (The Marshall Project). For those with addiction who live on the lower edges of socioeconomic status, overdose prevention sites can be a lifesaver, but communities often see these lives as less-than-equal to the costs of property crimes (The Pittsburgh Post-Gazette).

At times, society has enacted laws to address these inequalities. Cannabis legalization is often framed as a remedy to unjust criminalization, which makes sense, but that alone is not enough to make sense of legalization (The New York Times). Interestingly enough, the Americans with Disabilities Act is one of the most sensible laws protecting equality in addiction and it’s starting to have an impact on harm reduction (STAT). 

This is promising because many of the barriers to addiction recovery are about equal access to prevention and treatment. Research has shown how low-threshold treatment can reduce barriers to access but doesn’t appear to address the more systemic challenges with retention (Journal of General Internal Medicine). Even research about peer navigators shows how heterogeneous the experience of inequality can be and the many downstream challenges that come from it (JAMA Network Open).

It’s important to recognize how closely connected inequality is to addiction so we are better able to address it. Whether it’s an individual's desire to live (Journal of Psychiatric Research) or a colleague's desire to work, our best approach will always start with compassion (Journal of Clinical Anesthesia).

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 

2026 Addiction Medicine Research Priorities

ASAM is requesting your input on which areas of addiction clinical practice are most in need of further research. This input will be shared with federal research agencies, including the National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), and Agency for Healthcare Research and Quality (AHRQ). We are also planning a listening session called "Bridging the Gap between Science and Clinical Practice" with federal research agency representatives at the ASAM 57th Annual Conference.

Apply to be the ASAM Weekly Editor in Chief!

ASAM Weekly, with a circulation of 70,000 readers, is conducting a search for a new Editor in Chief (EIC). The EIC will serve a 1-year term from July 1, 2026, to June 30, 2027, with the option to renew for additional years. Benefits and compensation offered.

For a full job description and to apply, please click here.

Lead Story

Use of gabapentin with or without a prescription in substance use treatment settings: A national analysis of urine drug testing data, 2016–2023 🔓

Drug and Alcohol Dependence

Gabapentin prescriptions have increased due to off-label use, including managing withdrawal/comorbidities in substance use disorder (SUD) treatment, despite gaps in evidence bases and corresponding increases in nonmedical use. This retrospective, serial cross-sectional study sought to identify trends in gabapentin use with and without a prescription in SUD treatment settings. Researchers found that gabapentin prescribing significantly increased in SUD treatment settings despite a lack of strong evidence bases for its utility. While rates of gabapentin use outside a prescription were nearly double that for prescribed use, this appears to be decreasing over time. Polysubstance use and potential gaps in multimorbidity care may contribute to the use of gabapentin without a prescription.

Research and Science

Implementation Outcomes of Low Threshold Care for Persons with Opioid Use Disorders 🔓

Journal of General Internal Medicine

This is a prospective cohort study to evaluate low-threshold care (LTC) measures in primary care as predictors of implementation outcomes. Researchers used secondary data from the Addiction Treatment Starts Here practice change program which was implemented in 20 California primary care clinics interested in starting services with medications for opioid use disorder (MOUD). LTC models embrace person-centered care, emphasize risk reduction rather than abstinence-only models, and provide accessible services, including walk-in hours and lack of counseling requirements. The study developed and explored four tiered LTC composite measures (ranging from two to 12 items) based on the Integrating Medications for Addiction Treatment in Primary Care – Equity Version (IMAT PCE). The LTC measures were then compared with implementation outcomes based on the RE-AIM framework, assessing reach, effectiveness, adoption, implementation, and maintenance, with “new patient reach” as the primary outcome. Clinics that received implementation support showed increases in LTC scores over time, which predicted improvements in patient reach.

Peer Navigator Intervention and Opioid-Related Adverse Events for Emergency Department Patients: A Randomized Clinical Trial 🔓

JAMA Network Open

This randomized controlled trial enrolled 247 participants after non-fatal opioid-involved overdose across four emergency departments in New York City from October 2020 to June 2022. Of the participants, 125 were randomized to receive the Relay peer navigator and 122 were randomized to usual site-directed care with naloxone education and referral information. The Relay initiative included peer wellness advocates who met with patients in the emergency department (ED) and attempted to maintain contact with patients for the following 90 days to provide peer support and referrals. The primary outcome was opioid-related adverse events, including any opioid-involved overdose or substance use-related ED visit in the 12 months after enrollment. Overall, 9.7% of participants died within 12 months after baseline, with no statistically significant difference between the two groups (7.2% in the Relay arm and 12.3% in the site-directed care arm). Of the deaths, 70.8% were due to overdose. Overall, although the study did not find a statistically significant difference, it highlights the need for further research on peer-delivered interventions, as well as an urgent need for ED-delivered interventions.

Prevalence of Illicit Drug Detection in 5 US Cities Among Out-of-Treatment People Who Inject Drugs 🔓

JAMA Network Open

This cross-sectional study of 444 people who inject drugs assessed the prevalence of illicit drug detection among people who inject drugs who are not engaged in medical care across 5 US cities. Fentanyl was detected among 93%, xylazine among 53%, polysubstance drugs among 95%, and amphetamine among 67%; unhoused and recently incarcerated individuals had higher prevalence of cocaine and stimulant detection, respectively. Amphetamine prevalence increased over time in Washington, DC, and Philadelphia had the highest prevalence of xylazine detection. The findings suggest localized, real-time drug surveillance for out-of-treatment individuals who inject drugs, often missed by traditional public health systems, is needed.

Repeated fentanyl abstinence intensifies opioid withdrawal and induces a proinflammatory state in striatal microglia 🔓

Psychopharmacology

Concerns about opioid withdrawal are reported as a significant barrier to abstinence and initiation of treatment among persons with opioid use disorder (OUD). In addition, prior evidence has shown that repeated alcohol withdrawal episodes can lead to more severe withdrawal symptoms. Researchers sought to examine if repeated opioid withdrawal episodes lead to increased withdrawal severity using a mouse model. Transgenic mice were given fentanyl and underwent withdrawal for 1 or 5 cycles and those who underwent 5 cycles displayed more marked hyperalgesia that was sustained longer, evidence of greater anhedonia, and increased anxiety-like behavior. In addition, the group undergoing 5 cycles demonstrated changes in microglial gene expression with a pro-neuroinflammatory profile. The authors suggest therapies targeting this proinflammatory signaling could have a significant impact on OUD treatment.