Urine drug testing (UDT) plays a central role in monitoring substance use during pregnancy and the postpartum period, with results carrying significant legal and social consequences, including family separation. We present 2 cases of individuals with opioid use disorder who continued testing positive for fentanyl on UDS for 170 and 210 days, respectively, after their last reported use. Both cases involved a fentanyl cutoff threshold of 0.5ng/mL. In case 1, a 33-year-old male remained intermittently positive for 170 days, with fentanyl levels ranging from 0-7.1ng/mL. In case 2, a 33-year-old female remained intermittently positive for 210 days, with fentanyl levels ranging from 0-1.9ng/mL. Both individuals maintained low but detectable fentanyl concentrations throughout this extended period. These prolonged positive results delayed child custody reunification for both families. Despite mounting evidence of prolonged fentanyl detection, many agencies continue to rely on outdated guidelines suggesting fentanyl persists for only 1-3 days after last use. Without national standards for fentanyl detection window cutoffs, individuals maintaining abstinence continue to be suspected of recent use based solely on positive UDT results. We urge clinicians and child welfare professionals to consider these extended detection windows when interpreting positive fentanyl tests and to avoid misattributing persistently low positive results to recent drug use. These findings underscore the urgent need to revise decision-making frameworks to prevent harm to families and ensure appropriate clinical and legal outcomes.

The current study aimed to estimate the percentage of US adults who disagree or do not know that addiction is a health condition and explore associations between disagreement that addiction is a health condition with indicators of beliefs about addiction treatment and intentions to support loved ones with addiction. A nationally representative sample of US adults was recruited from Gallup's probability-based panel. A total of n=5250 (out of n=12,500 invited) responded to a web-based survey including questions about beliefs about drug or alcohol addiction and treatment. Survey sample weights were applied to correct for unequal selection probability and nonresponse rates, and data were analyzed using descriptive statistics and regression. Close to one-quarter of US adults (23.0%) are estimated to either disagree or not know that addiction is a health condition. Respondents who disagreed or did not know that addiction is a health condition were less likely to believe that addiction is treatable by health care professionals (disagreed: OR=0.33, 95% CI=0.28-0.39; did not know: OR=0.28, 95% CI=0.21-0.36), early intervention for addiction is helpful (disagreed: OR=0.57, 95% CI=0.48-0.66; did not know: OR=0.40, 95% CI=0.31-0.53), or medications are effective treatments for addiction (disagreed: OR=0.47, 95% CI=0.40-0.55; did not know: OR=0.28, 95% CI=0.21-0.37). They were also less likely to indicate that they would help a loved one with addiction (disagreed: OR=0.50, 95% CI=0.40-0.63; did not know: OR=0.65, 95% CI=0.44-0.97). US adults likely have heterogenous views on addiction, and more research is needed to further understand how US adults conceptualize addiction.

Illness severity may influence the relationship between opioid use disorder (OUD) and adverse outcomes, yet factors affecting severity are not fully understood. The objective of this study is to examine sociodemographic and hospital-related factors associated with severity among OUD-related hospitalizations. We used data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2015 to 2022. The HCUP NIS includes severity measures that assign patients overall severity of illness (SOI) and risk of mortality (ROM) subclasses (ie, minor, moderate, major, and extreme) based on their secondary diagnoses and other clinical characteristics (eg, age, procedures). Partial proportional odds models were used to measure the association between sociodemographic/clinical factors and SOI/ROM subclass severity among OUD-related hospitalizations. SOI shifted toward more severe subclasses in 2019-2022 and ROM in 2015-2022 (higher share major/extreme). Medicare and self-pay, compared with private insurance, were associated with higher odds (adjusted odds ratio [aOR] [95% CI]) of extreme SOI (vs. minor, moderate, or major) (Medicare: 1.07 [1.05, 1.09]; self-pay: 1.08 [1.05, 1.11]). Rural hospitals, compared with urban ones, had lower odds of higher SOI severity (aOR 0.80 [0.77, 0.82]). Results were similar for ROM. Age, sex, race, income, region, hospital size, admission timing, and admission type were also significantly associated with SOI/ROM. Structural/systematic factors play a role in shaping the course of inpatient OUD. These findings highlight the need to strengthen hospital addiction care capacity, address insurance and income-related inequities, and develop targeted inpatient risk stratification strategies to improve outcomes for patients with OUD.

Posttraumatic stress disorder (PTSD) during pregnancy is associated with adverse consequences and has an estimated prevalence of 3% in community samples. The prevalence of current PTSD among pregnant women with opioid use disorder (OUD), a population at increased risk of adverse birth outcomes and other mental disorders, has been estimated at 16%-37% based on 3 small studies. We used the Centers for Disease Control and Prevention's MATernaL and Infant clinical NetworK (MAT-LINK) surveillance network to (1) further examine current PTSD prevalence among pregnant women with OUD and (2) compare characteristics of those with and without PTSD. PTSD prevalence estimates during the current pregnancy were based on (1) presence of an ICD-9/10-CM code indicating PTSD (ie, extracted); (2) documentation of a PTSD diagnosis in abstracted data (ie, abstracted); and (3) PTSD identified by either source. Of 3315 pregnancies among women with OUD, estimated current PTSD prevalence was 14.7% (95% CI: 13.5-15.8) based on extracted data alone, 23.3% (95% CI: 22.0-24.6) based on abstracted data alone, and 25.9% (95% CI: 24.1-27.7) when based on either data source. Those with PTSD had a higher prevalence of most substance use and mental health disorders examined compared with those without. These estimates underscore the substantial prevalence of PTSD among pregnant women with OUD and emphasize the need to screen for and treat PTSD and other mental health disorders in this population. Given that evidence-based treatments for PTSD have not been systematically evaluated in pregnant women, more research is sorely needed.

Clinicians have prescribed benzodiazepines for a range of symptoms and conditions since the Food and Drug Administration approved chlordiazepoxide in 1960. Between 1969 and 1982, the benzodiazepine diazepam was the most prescribed medication in the United States. Since then, recognition of benzodiazepine's risks-such as falls, psychomotor and cognitive impairment, withdrawal, benzodiazepine use disorder (BzUD), and suicidality-and limited data on long-term safety and efficacy have created challenges for clinicians and patients, including when and how to safely taper these medications. In 2025, 10 professional societies, including the American Society of Addiction Medicine (ASAM), released the Joint Clinical Practice Guideline on Benzodiazepine Tapering. This commentary explores implications for addiction treatment.

The contamination of non-opioid drugs with fentanyl presents a risk at US music festivals, where environmental factors exacerbate overdose-related risks. Naloxone is an opioid antagonist medication that can be used by festival attendees to reverse opioid overdose. We conducted a field survey at a 4-day Colorado music festival (N=227) to characterize attendees' prior experience with naloxone and to investigate whether attendees carry naloxone with them in both festival and non-festival settings. We also assessed attendees' level of confidence in responding to an overdose with naloxone and asked attendees to report any barriers they experienced to carrying naloxone at festivals. Prevalence of carrying naloxone in any context was 55.5% (N=126). Festival carriage was more common than carriage in non-festival settings, with 55.1% reporting at least "sometimes" carrying at festivals compared with 32.7% outside festival settings. In addition, 8.4% had used naloxone to respond to an overdose, and 4.4% had personally been administered naloxone. Among participants who reported carrying naloxone, 65.3% had never received training. Regarding confidence in overdose response, 29.9% of naloxone carriers reported being only "slightly confident" or "not at all confident." Barriers included access, festival restrictions and legal concerns, lack of education, training, and awareness, convenience factors, and perceived responsibility of carrying naloxone. Findings highlight the need for increased naloxone access, training, and awareness among festival attendees. Actionable recommendations include free or low-cost naloxone distribution, on-site training, and transparent entry policies to reduce barriers and promote overdose response as a community responsibility.

Buprenorphine may be offered less frequently than indicated for treatment of opioid withdrawal in the emergency department (ED) due to patient and clinician concerns regarding precipitated withdrawal (PW). Our objective is to determine an accurate estimate of the incidence of PW following buprenorphine initiation in the ED. We performed a retrospective study of adults seen in one of the 15 EDs within the University of Maryland Medical System who received ED-initiated buprenorphine between January 1, 2019 and December 31, 2023. Patients were excluded if they were given buprenorphine to continue an established treatment regimen, had buprenorphine ordered by an inpatient clinician, or did not have a Clinical Opiate Withdrawal Scale (COWS) score recorded before treatment. PW was defined as either a ≥5-point increase in COWS score within 4 hours of buprenorphine administration or any increase in the COWS score associated with additional opioid administration within 4 hours of the first buprenorphine dose. A total of 1229 patients received buprenorphine in the ED during the study period; 990 were excluded. We identified 16 cases of PW [6.7% (95% CI: 3.5%-9.9%)]. No association was found between the development of PW and initial COWS, buprenorphine formulation, fentanyl use, or buprenorphine dose. PW was uncommon following ED-initiated buprenorphine in this cohort. However, the rate of PW was higher than reported in some prior studies. Patients should be counseled regarding the possibility of PW before treatment, and clinicians should be prepared to address symptoms of PW when they occur.

Functional magnetic resonance imaging studies have shown that smoking cues activate reward-related brain regions, with activation intensity increasing with smoking addiction severity. A recent study on cocaine addiction reported increased striatal glutamatergic tone in response to cocaine-associated cues; however, the role of glutamate in smoking cue-induced brain activation and its relationship with addiction severity remain unclear. This study investigated glutamate modulation in the anterior striatum and dorsal anterior cingulate cortex (ACC) of male participants, comprising smokers (n = 38) and healthy controls (n = 48), exposed to smoking cues. Magnetic resonance spectroscopy (MRS) was used to measure glutamate levels at baseline (neutral images) and during smoking cue (smoking images) presentation. A mixed-model ANOVA followed by post hoc paired t tests revealed a significant increase in striatal glutamate levels in smokers exposed to smoking cues, whereas no changes were observed in controls. This effect on striatal glutamate in smokers remained significant after controlling for age. No significant changes were observed in the ACC in either smokers or controls. Although a positive association trend was found between smoking severity, as measured by the Fagerström Test for Nicotine Dependence (FTND) scores, and striatal cue-induced glutamate changes, it was not statistically significant. These findings suggested that smoking cue-induced increases in striatal glutamate tone may reflect the neurochemical mechanisms underlying cue-induced phenomena in humans.

The United States continues to experience an opioid overdose epidemic with mortality patterns that reflect existing social and environmental inequities. Although research has examined various factors associated with opioid-related mortality, the relationships between social-environmental vulnerability (SEV), health care presence, and geography remain poorly characterized. To explore whether SEV accelerates opioid overdose rates and to assess how the presence of health care services-specifically opioid treatment programs (OTPs) and primary care providers (PCPs)-modifies these patterns across rural and urban contexts. A retrospective ecological analysis using hierarchical linear modeling was conducted from January 2020 to December 2022, analyzing 172,359 observations across 57,453 census tracts within 1219 US counties. The primary exposure was census-tract-level SEV, operationalized using the CDC Environmental Justice Index. Health care indicators included county-level presence of OTPs and PCPs. Areas in the highest quartile of SEV demonstrated elevated acceleration coefficients (β=3.224; SE=0.803; P<.001), with pronounced patterns observed in rural areas, though ecological design limitations preclude individual-level causal inference. Interaction analyses suggested that high-SEV counties containing both OTP and primary care resources demonstrate lower acceleration coefficients (β= -11.478, SE=5.429, P=0.035). Areas without health care presence showed higher baseline rates in overdose acceleration, particularly in urban high-vulnerability settings. High SEV was associated with accelerated opioid overdose rates during 2020-2022, particularly in rural areas. The presence of OTPs and primary care services within counties was associated with attenuated acceleration in high-vulnerability areas. This may indicate that policies prioritizing comprehensive health care services in high-SEV communities could address opioid overdose disparities.

Hospitalization and emergency department (ED) visits are an underutilized opportunity to reach high-risk patients with opioid use disorder (OUD) with buprenorphine (BUP) treatment and reduce the ongoing and widespread treatment gap. Monthly extended-release BUP (XR-BUP) potentially facilitates successful initiation and delivers sustained treatment. XR-BUP provides up to 30 days of medication for opioid use disorder (MOUD) with each administration and could improve retention in care during transition to outpatient addiction treatment. We aim to describe the patient characteristics and clinical outcomes of hospitalized and ED patients with OUD treated with monthly XR-BUP. We conducted a retrospective chart review of a cohort of ED or hospitalized patients who received monthly XR-BUP at an urban, safety-net hospital over a 6-month period from September 2023 through March 2024. There were 61 patient encounters where XR-BUP was administered. Within 30 days of discharge, 40/61 (65.6%) patients who received XR-BUP engaged in outpatient addiction treatment through an in-person or telemedicine provider visit; within 45 days, 29/61 (47.5%) patients received a subsequent XR-BUP. Thirty-eight (62.3%) initiated XR-BUP with low-dose initiation of sublingual buprenorphine with full agonist opioid continuation, 20 (32.8%) started after high-dose sublingual buprenorphine, 2 (3.3%) after low-dose initiation of IV buprenorphine, and 1 (1.6%) received "direct to inject" XR-BUP. In this observational retrospective study, rates of engagement in addiction treatment after discharge among patients with OUD receiving XR-BUP were high. Clinical teams utilized novel strategies to initiate XR-BUP during ED and hospital-based encounters.