ASAM Practice Pearls

In this season 2 finale of ASAM Practice Pearls, Dr. Stephen Taylor sits down with Dr. Timothy Fong to discuss one of the fastest-growing and most overlooked concerns in addiction medicine: gambling disorder. With sports betting now legal in over 40 states and digital gambling accessible on every smartphone, gambling and sports betting are rapidly expanding. This episode breaks down the prevalence, consequences, and unique aspects of gambling disorder and offers practical, actionable guidance on screening, brief intervention, and treatment. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at [email protected]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Timothy Fong, MD Dr. Timothy Fong is the President of the American Academy of Addiction Psychiatry (AAAP) and a clinical professor of psychiatry at the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA. He is board certified in adult and addiction psychiatry. He is the co-director of the UCLA Gambling Studies Program, a program that examines the clinical characteristics of gambling disorder in order to develop effective, evidence-based prevention and treatment strategies. Dr. Fong is also a member of the Steering Committee of the UCLA Center for Cannabis and Cannabinoids, whose mission is to address the most pressing questions about the impact of cannabis legalization through rigorous scientific study and interdisciplinary discourse. He is a member of the UCLA Sports Psychiatry Service and the UCLA Sports Medicine Mental Health Team. 📖 Show Segments 00:05 - Introduction  02:38 - Modern Day Gambling: Investing vs Gambling vs Betting 04:38 - Prevalence and Public Health Impact 08:21 - Consequences of Gambling Disorder 14:30 - Screen and Clinical Assessment 20:03 - Interventions and Treatment Options 23:59 - Practice Pearls 27:40 - Conclusion 📋 Key Takeaways Recognize that we are practicing in a gambling-centered environment: The rapid expansion of mobile sports betting, online wagering, and prediction markets has normalized gambling and lowered perceptions of risk. Clinicians should expect to encounter gambling-related harms more frequently across patient populations. Recognize gambling disorder as a serious and potentially life-threatening condition: Gambling disorder is associated with high rates of suicidality, co-occurring substance use disorders, mental health disorders, financial strain, relationship problems, and intimate partner violence. Clinicians should approach it with the same level of concern as substance use disorders. Remember that gambling disorder is often a hidden addiction: Patients may appear highly functional, professionally successful, and psychologically intact while experiencing severe financial losses, emotional distress, and compulsive gambling behaviors. Do not rely on appearance or external functioning to assess risk. Screen routinely and ask the right questions: Gambling should be assessed alongside substance use during intakes, annual assessments, and follow-up visits. Because many patients do not view sports betting, poker, online wagering, or prediction markets as "gambling," ask specifically about betting behaviors. Consider questions such as: Have you ever lied to anybody about spending money on gambling or betting? Have you ever increased your bet, wager, or gambling amount to get the same thrill or rush? How much time, energy, and money do you spend online trying to make more money? Assess financial health as part of both screening and recovery: Ask patients about debt, paycheck-to-paycheck living, loans, and financial stress. Financial difficulties may uncover gambling-related harms that patients are reluctant to disclose, and addressing financial wellness should be part of ongoing recovery planning. Think about gambling when patients are not improving as expected: If depression, anxiety, substance use treatment, or other behavioral health conditions are not improving as expected, consider whether an undiagnosed gambling disorder might be contributing to ongoing distress or risk of return to use. Use brief physician interventions to increase motivation for change: A nonjudgmental conversation that connects gambling behavior to physical health, mental health, finances, and overall well-being can have a meaningful clinical impact. Just two to three minutes can make a difference. Remember to always frame concerns in a supportive, motivating way. Apply a biopsychosocial approach to treatment: Treatment should address biological, psychological, and social factors by supporting healthy sleep, nutrition, and physical activity, treating co-occurring psychiatric and substance use disorders, and connecting patients to appropriate therapeutic and recovery resources. Use harm-reduction goals when appropriate: Help patients develop realistic, measurable goals, such as reducing gambling expenditures or limiting gambling frequency. Revisit those goals regularly and adjust the treatment plan based on progress, just as you would for any other substance use disorder. Create a gambling disorder toolkit for your practice: Maintain referral pathways to gambling-certified therapists, Gamblers Anonymous meetings, telehealth services, helplines, and digital recovery tools. Incorporate screening tools, patient education resources, and community support into your existing addiction treatment workflows so gambling becomes part of routine clinical care. 🔗 Resources ASAM Review Course 2026: Behavioral Addiction: Criteria, Challenges, and Considerations ASAM’s Special Interest Group: Behavioral Addictions Community Screening Tools: Brief Biosocial Gambling Screen (BBGS) DSM-5 Criteria for Gambling Disorder Emerging Adult Gambling Screen (EAGS-4) Gambling Harms Scale-20 (GHS-20) Internet Gaming Disorder Test-20 (IGD-20) The South Oaks Gambling Screen (SOGS) National Gambling Problem Helpline: 1-800-MY-RESET Gamblers Anonymous Meeting Locator: GamblersInRecover.com Telehealth Gambling Treatment Providers: Kindbridge Behavioral Health Birches Health Digital Recovery App: EVIVE digital health tool Voices in Recovery Podcast Series: ALL IN: The Addicted Gambler’s Podcast The Broke Girl Society Gambling Addiction Conferences: The National Conference on Problem Gambling (NCPG) Annual Conference The International Center for Responsible Gaming (ICRG) Annual Conference on Gambling and Addiction 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor welcomes back Dr. Stephanie Weiss and is joined by Dr. Anna Lembke to explore an update on GLP-1 receptor agonists for alcohol use disorder (AUD), discussing current research, how things have evolved since the last discussion, and the challenges and implications of integrating these innovative treatments into addiction care. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at [email protected]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Stephanie Weiss, MD, PhD Dr. Stephanie Weiss is a Research Physician with the Translational Addiction Medicine Branch (TAMB) of the NIDA Intramural Research Program. She holds a PhD in pharmaceutical chemistry and a medical degree from the Cleveland Clinic Lerner College of Medicine. Board-certified in emergency medicine, addiction medicine, and medical toxicology, Dr. Weiss focuses on caring for patients with poisonings, overdoses, and medication misuse. Her research interests include novel psychoactive substances, medication misuse, and improving urine drug testing interpretation. Expert Anna Lembke, MD, FASAM Dr. Anna Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is currently Professor and Medical Director of Addiction Medicine, Stanford University School of Medicine. She is also Program Director of the Stanford Addiction Medicine Fellowship, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, and a diplomate of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine. 📖 Show Segments 00:05 - Introduction  04:15 - Latest Developments in Research 05:34 - Prescribing GLP-1's Off Label 06:28 - Challenges With Prescribing 07:36 - Who Benefits From GLP-1's and Who Doesn't 09:52 - Potential for Other SUD Treatment Beyond AUD 11:18 - Side Effects, Tolerability Concerns, and Adherence Challenges 15:11 - Where GLP-1's Fit into the Treatment Toolbox 16:19 - Unanswered Questions about GLP-1 Treatment 19:14 - GLP-1's Possible Impact on Mood 25:11 - Dosing Strategy and Titration Approach 26:36 - Life After GLP-1s: Rebound Risk and "Chipping" 28:52 - Biggest Surprise from the Research So Far 31:05 - Practice Pearls 32:34 - Conclusion and Additional Learning Opportunities 📋 Key Takeaways Emerging evidence continues to build for GLP-1s in AUD: Multiple recent clinical trials of semaglutide for AUD have reported positive findings, with additional studies expected to be published in the coming year. While the evidence base is growing, GLP-1s are not yet FDA-approved for the treatment of substance use disorders. Continue to prioritize FDA-approved medications for AUD first: Clinicians should start with established treatments such as naltrexone, acamprosate, and disulfiram before considering off-label GLP-1 therapy. Consider GLP-1s for patients with AUD and relevant co-occurring conditions: Patients with refractory AUD who have not responded well to evidence-based treatments and also have obesity, diabetes, binge eating disorder, food addiction, or treatment-resistant depression may be good candidates for a GLP-1 trial. Start low and titrate based on efficacy and tolerability: There is currently no established optimal GLP-1 dose for AUD. Clinicians prescribing GLP-1s off-label should begin with low doses and gradually titrate while monitoring symptom improvement and adverse effects. Note: A 7.2 mg injectable semaglutide dose was approved in March 2026 for chronic weight management. Although this dose has not been studied in clinical trials for AUD, its availability may be relevant for patients who experience only a partial response at lower semaglutide doses. Prepare patients for common gastrointestinal side effects: Nausea, constipation, diarrhea, abdominal discomfort, belching, reflux, and worsening GERD symptoms are among the most commonly reported adverse effects. Many patients adapt over time, and symptoms may improve despite subsequent dose increases. Monitor for changes in mood, motivation, and reward-seeking behaviors: In addition to reduced cravings for alcohol, some patients report diminished interest in food, pleasurable activities, or other rewarding experiences. At the same time, emerging evidence suggests GLP-1s may improve mood in some individuals, though further research is needed. Use a multidisciplinary approach to prescribing and monitoring: Collaboration with primary care clinicians, GI specialists, or other medical providers can help address insurance barriers, monitor adverse effects, and support comprehensive patient care. Evidence for other substance use disorders remains preliminary: The use of GLP-1s for AUD may be unique due to its caloric content; however, researchers are actively studying GLP-1s for other substance use disorders, but current data are still limited. Clinicians should remain cautious until more robust evidence becomes available. Long-term treatment questions remain unanswered: It is still unclear how long patients should remain on GLP-1 therapy, whether benefits persist after discontinuation, and whether some patients experience relapse or rebound symptoms when treatment stops. Consider GLP-1s as an additional tool, not a replacement for comprehensive care: The greatest benefit is likely achieved when medications are combined with psychosocial interventions, counseling, mutual-support participation, and ongoing recovery-oriented care. 🔗 Resources Season 1 Episode: GLP-1 Receptor Agonists Explained: Their Potential Role in Addiction Treatment ASAM 56th Annual Conference: The Science of GLP-1 Receptor Agonists: A Rising Tide in Addiction Treatment Heavy Hitters: Glucagon-like Peptide-1 (GLP-1) Receptor Agonists for Addiction Treatment ASAM 57th Annual Conference Posters: GLP-1 Receptor Agonists Improve Outcomes in Patients Receiving Buprenorphine for OUD Consequences of GLP-1 Coverage Loss in Alcohol Use Disorder Journal of Addiction Medicine Journal Article Activity: The Efficacy of GLP-1 Agonists in Treating Substance Use Disorder in Patients A Scoping Review Does Semaglutide Reduce Alcohol Intake in Danish Patients With Alcohol Use Disorder and Comorbid Obesity? Trial Protocol of a Randomised, Double-Blinded, Placebo-Controlled Clinical Trial (the SEMALCO trial) - Klausen MK, Kuzey T, Pedersen JN, et al. BMJ Open. 2025;15(1):e086454. Published 2025 Jan 8. doi:10.1136/bmjopen-2024-086454 Once-Weekly Semaglutide in Adults With Alcohol Use Disorder: A Randomized Clinical Trial - Hendershot CS, Bremmer MP, Paladino MB, et al. JAMA Psychiatry. 2025;82(4):395-405. doi:10.1001/jamapsychiatry.2024.4789 Once-Weekly Semaglutide Versus Placebo in Patients With Alcohol Use Disorder and Comorbid Obesity: A Randomised, Double-Blind, Placebo-Controlled Trial - Klausen MK, Justesen SK, Pedersen JN, et al. The Lancet. 2026;407(10540):1687-1698. doi:10.1016/s0140-6736(26)00305-3 Oral Semaglutide for Alcohol Use Disorder: A Randomized Clinical Trial - Schacht JP, Sakai JT, Raymond K, Shelton R. Am J Psychiatry. Published online July 29, 2026. doi:10.1176/appi.ajp.20260003 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts Dr. Justin Berk to discuss addiction care for individuals involved in the criminal justice system, including patients in custody and those transitioning back to the community. The conversation explores practical strategies for building therapeutic alliances with incarcerated patients, advocating for evidence-based treatment in correctional settings, and navigating common barriers to care. The episode covers opportunities for clinicians to provide compassionate, patient-centered care that improves outcomes for this high-risk population. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at [email protected]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Justin Berk, MD, MPH, MBA, FASAM Dr. Justin Berk is an addiction medicine physician-researcher and the former Medical Director of the Rhode Island Department of Corrections. He is an Associate Professor in the Departments of Medicine and Pediatrics at the Alpert Medical School at Brown University and the Director for the Center of Health and Justice Transformation at Brown University Health. He completed residency at the Urban Health Combined Internal Medicine – Pediatrics Residency Program at Johns Hopkins Hospital and is Board Certified in Internal Medicine, Pediatrics, and Addiction Medicine. His research and advocacy focus on the intersection of addiction medicine, correctional health, and health equity. 📖 Show Segments 00:05 - Introduction  03:09 - Building Rapport with Patients in Custody 08:23 - Evidence for MOUD in Jails and Prisons 11:05 - Overcoming Implementation Barriers for Evidence-based Treatment 13:11 - Advocating for Patients in Custody 17:25 - Reentry and Continuity of Care 19:44 - Addressing Diversion Concerns 23:22 - Privacy, Autonomy, and Care Coordination 24:50 - Lightning Round Q&A 28:05 - Practice Pearls 29:58 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways Recognize the justice system as a critical treatment touchpoint: Approximately 58% of individuals in state prisons and 63% of individuals in jails meet criteria for substance use disorder, making correctional settings an important, and often underutilized, opportunity to initiate evidence-based addiction care. Tailor clinical management to the correctional setting: Jails and prisons present distinct clinical challenges, with jails more commonly managing acute intoxication, withdrawal, and trauma, while prisons often focus on chronic disease management and long-term care. Use humanistic, patient-centered care to improve engagement and outcomes: Small actions, such as requesting the removal of handcuffs during clinical encounters, advocating for privacy, facilitating necessary evaluations, and coordinating directly with correctional facilities during transitions of care, can build trust and strengthen therapeutic relationships. Use hospitalization to close care gaps for patients in custody: When feasible, initiate evidence-based treatments during hospitalization rather than deferring care. Consider starting HCV treatment, optimizing medication for opioid use disorder (MOUD), addressing rehabilitation needs, completing necessary diagnostic workups, and documenting ongoing care requirements. Support access to MOUD in correctional settings: Evidence demonstrates that methadone and buprenorphine save lives, reduce overdose risk, improve treatment retention, and improve outcomes, yet many of these treatments remain unavailable in many correctional facilities. Recommend and document evidence-based treatment regardless of anticipated barriers: When MOUD is clinically indicated, formally prescribe or recommend treatment, even if continuation is uncertain, to create a clear record of the standard of care and support future treatment access. Balance diversion concerns against the benefits of treatment: While diversion of medications such as buprenorphine can occur, concerns are often overstated and should not prevent patients from receiving evidence-based treatment for opioid use disorder. Prioritize overdose prevention during the reentry period: Individuals face an exceptionally high risk of fatal overdose immediately after release, making reentry planning, continuity of care, and ongoing treatment engagement essential components of addiction treatment. Plan for reentry early and proactively: Because 95% of incarcerated individuals return to their communities, clinicians should address barriers such as insurance coverage, identification, housing, transportation, and continuity of care before release whenever possible. Maintain a high index of suspicion for alcohol withdrawal in custody settings: Alcohol withdrawal is a high-risk situation in jails, and is often underrecognized and potentially fatal, requiring early identification, monitoring, and treatment. 🔗 Resources The ASAM Criteria, Fourth Edition, Volume 3: Correctional Settings and Community Reentry Volume Public comment open until August 31, 2026 Expected release early 2028 (tentative) Treatment of SUD in Jails and Prisons (FREE) ASAM Clinical Tips: Treating SUD in Jails and Prisons Implementing MOUD Improves Safety, Culture, and Public Health Managing Alcohol Withdrawal in Jail Settings Additional Treatment Courts Education (FREE) Learning Collaborative Sessions (Mentoring) - A Whole Person Approach: Adding Addiction Medicine Services to a Drug Treatment Court Program Resources: Job Aids Treatment Court Resources & Toolkits MOUD Guides ASAM Public Policy Statement on Treatment of Opioid Use Disorder in Corrections Settings - Adopted by the ASAM Board of Directors on July 15, 2020; revised on January 23, 2025 Guidelines for Managing Substance Withdrawal in Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals - Bureau of Justice Assistance, Office of Justice Programs, US Department of Justice; June 2023 Jail and Prison Opioid Project: This website provides data, research, implementation resources, and an interactive database documenting which correctional facilities offer evidence-based treatments such as methadone, buprenorphine, and naltrexone to individuals with opioid use disorder. Justice Community Overdose Innovation Network (JCOIN): An NIH-funded national initiative focused on improving how the criminal justice system responds to substance use disorders by advancing research, evidence-based practices, and partnerships between healthcare and justice systems. This website provides research, training, technical assistance, and educational resources to expand access to effective addiction treatment for justice-involved populations. Association Between Jail-Based Methadone or Buprenorphine Treatment for Opioid Use Disorder and Overdose Mortality After Release From New York City Jails 2011-17 - Lim S, Cherian T, Katyal M, et al. Addiction. 2023;118(3):459-467. doi:10.1111/add.16071 Carceral Health Care - Brinkley-Rubinstein L, Berk J, Williams BA. N Engl J Med. 2025;392(9):892-901. doi:10.1056/NEJMra2212149 Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009 (Revised 2020) - Bronson J, Stroop J, Zimmer S, Berzofsky M. Bureau of Justice Statistics, US Department of Justice; June 2017. NCJ 250546 Hospitalization Through the Lens of Incarceration - South AM, Haber LA, Berk J. J Gen Intern Med. 2024;39(10):1905-1909. doi:10.1007/s11606-024-08805-8 Injecting Opioid Use Disorder Treatment in Jails and Prisons: The Potential of Extended-Release Buprenorphine in the Carceral Setting - Berk J, Del Pozo B, Rich JD, Lee JD. J Addict Med. 2022;16(4):396-398. doi:10.1097/ADM.0000000000000942 Reentry Trends in the United States - Hughes TA, Wilson DJ. U.S. Department of Justice, Bureau of Justice Statistics; 2004 Uncommon and Preventable: Perceptions of Diversion of Medication for Opioid Use Disorder in Jail - Evans EA, Pivovarova E, Stopka TJ, Santelices C, Ferguson WJ, Friedmann PD. J Subst Abuse Treat. 2022;138:108746. doi:10.1016/j.jsat.2022.108746 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor welcomes Dr. Itai Danovitch to discuss the descriptive term polysubstance use and methods for evaluating and managing patients with polysubstance intoxication and unknown toxidromes. The conversation covers strategies for assessing altered mental status, maintaining a broad differential diagnosis, safely managing agitation, and providing supportive care while avoiding common cognitive biases. This episode offers listeners practical insights for navigating clinical uncertainty and supporting patients from stabilization to treatment engagement. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at [email protected]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Itai Danovitch, MD, MBA, DFAPA, DFASAM Dr. Itai Danovitch is Professor and Chair of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles. He earned his bachelor's degree from UC Berkeley and his medical doctorate from the UCLA School of Medicine. He completed a psychiatry residency at Columbia University, an addiction psychiatry fellowship at Cedars-Sinai Medical Center, and a Master of Business Administration at the UCLA Anderson School of Management. Dr. Danovitch’s clinical practice and research are focused on the treatment of substance use disorders and the integration of medical and mental health services. His research is funded by the National Center for Advancing Translational Sciences (NCATS), the National Institute on Drug Abuse (NIDA), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). He is the author of over 100 articles and book chapters and co-editor of two books on substance use disorders. Dr. Danovitch served as a Governor-appointed state Commissioner to the California Mental Health Services Commission. He is a Distinguished Fellow of the American Society of Addiction Medicine, a Distinguished Fellow of the American Psychiatric Association, and past president of the California Society of Addiction Medicine. 📖 Show Segments 00:05 - Introduction  02:28 - Chapter 59 in The ASAM Principles of Addiction Medicine 03:45 - Patient Case: Altered Mental Status 06:01 - Polysubstance Use as a Descriptive Term 07:53 - Approaching Unclear or Mixed Toxidromes 11:36 - Completing a Differential Diagnosis Workup 14:54 - Responding When There Is a Lack of Clear Protocols 18:39 - Contaminants and the Changing Drug Supply 20:39 - Practice Pearls 23:33 - Lightning Round Q&A 27:35 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways Conduct empirical evaluations and avoid confirmation bias: Polysubstance presentations often involve incomplete histories, unexpected substances, or contaminants. Remain comfortable with uncertainty, continually reassess the patient, and adapt management as new information emerges rather than becoming committed to an early diagnosis. Keep the differential diagnosis broad when evaluating altered mental status: Do not assume that all episodes of agitation, confusion, or delirium are caused solely by substance use. Consider intoxication, withdrawal, infection, trauma, metabolic disorders, neurologic conditions, and other medical causes. Supportive care is the foundation of managing most toxidromes: For many unknown or mixed toxidromes, treatment focuses on maintaining airway, breathing, circulation, temperature regulation, and patient safety while the body metabolizes and clears substances. Match agitation management to the underlying cause: Agitation related to withdrawal from central nervous system depressants may require benzodiazepines or barbiturates, while agitation or psychosis unrelated to withdrawal may be better managed with antipsychotic medications. Reassess frequently if symptoms fail to improve as expected. Create a calm, low-stimulation environment whenever possible: Reducing environmental stressors, providing reassurance, and avoiding the use of physical restraints (which can worsen agitation and lead to additional complications) can help improve outcomes and reduce complications in patients who are intoxicated or have an altered mental state. Toxicology screens are helpful but have limitations: Obtain toxicology testing early when appropriate, but do not rely on it exclusively. Some substances, such as GHB (gamma-hydroxybutyrate), may not be detected on routine screening tests, and negative results do not rule out exposure. Use local expertise to understand emerging drug trends: Emerging synthetic substances, contaminants, and adulterants can alter clinical presentations. Local surveillance data and poison control centers are valuable resources for understanding regional drug trends and obtaining management guidance. Treat agitation as a medical emergency rather than a behavioral inconvenience: Significant agitation may signal a serious underlying condition and requires prompt assessment, monitoring, and intervention. Engage patients with empathy and curiosity: Intoxication and altered mental status can be frightening and traumatic experiences. Use a supportive, patient-centered approach and learn from patients' experiences. Stabilization is only the beginning of care: Once a patient has recovered from intoxication or withdrawal, clinicians should engage them in conversations about substance use, provide harm reduction education, assess for substance use disorders, and connect them with evidence-based treatment when appropriate. 🔗 Resources The ASAM Principles of Addiction Medicine 7th Edition - Miller SC, Rosenthal RN, Levy S, Saxon AJ, Tetrault JM, Wakeman SE, eds. Wolters Kluwer; 2024. Chapter 59: Management of Stimulant, Hallucinogen, Cannabis, Phencyclidine, and Other Drug Intoxication and Withdrawal - Wilkins JN, Gorelick DA, Danovitch I, Athanasiou N, Allen S. Implementation Guide for Hospital and Emergency Department Substance Use Disorder Care 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts Dr. Stephen Holt in a discussion about practical strategies for initiating and managing patients receiving low-dose buprenorphine and long-acting injectable (LAI) formulations. The conversation explores how to match induction approaches to individual patient needs, guidance on dosing, and ways to support ongoing use, cravings, or withdrawal symptoms. This episode offers listeners practical insights for implementing buprenorphine treatment strategies and expanding access to evidence-based care. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at [email protected]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Stephen Holt, MD, MS, FACP, FASAM Dr. Stephen Holt has been an attending physician at Yale-New Haven Hospital since 2008 and is an Associate Professor of Medicine at Yale School of Medicine. He is the Director of the Yale Addiction Recovery Clinic and the Associate Program Director for Yale's Primary Care Internal Medicine Residency Program. He is board-certified in Addiction Medicine and Internal Medicine. He has published and lectures frequently on a variety of addiction medicine topics, and has won numerous teaching awards at the local, regional, and national levels. 📖 Show Segments 00:05 - Introduction  00:45 - Patient Case: Erratic use of Buprenorphine 02:23 - Deciding Between Traditional and Low-Dose Induction 05:27 - Direct-to-Inject Approach and Access Logistics 09:23 - Low-dose Induction Approach 10:38 - Considerations for Tailoring Buprenorphine Doses 12:37 - Candidates for LAI Formulations 14:16 - Initiating LAI Treatment 17:56 - Managing Ongoing Use and Breakthrough Symptoms on LAI 21:02 - Addressing Co-occurring Substance Use Disorders 23:05 - Practice Pearls 25:31 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways Match your induction strategy to the patient: Patients using short-acting or predictable opioids can follow a traditional induction. For those taking predictable long-acting opioids or methadone, consider a low-dose induction. For patients with erratic use of buprenorphine or fentanyl, consider a direct-to-inject or high-dose induction approach. Low-dose induction reduces the risk of precipitated withdrawal: Start a patient with very small amounts of buprenorphine (e.g., 0.5 mg) while the patient continues using their opioid, then gradually increase their buprenorphine dose over approximately 6 days in the outpatient setting. Consider direct-to-inject LAI buprenorphine for patients with unstable use: LAI buprenorphine (especially 7-day formulations) allows a gradual receptor transition, reducing withdrawal risk and simplifying care for patients with unstable opioid use patterns. Proactively address logistical barriers to offering LAIs: Establish feasible workflows (e.g., specialty pharmacy or buy-and-bill) to reduce access barriers. Another option is to plan follow-up visits a few days later to administer the injection and use sublingual buprenorphine as a bridge, rather than trying to secure LAI same-day access upfront. Individualize LAI dosing based on patient use patterns and context: There's no perfect conversion from fentanyl to buprenorphine. Dosing decisions depend on opioid type, level of cravings, and environment. Patients using more than 2-3 bags of fentanyl per day may require the maximum dose of LAI buprenorphine, whereas lighter users may not. Offer LAI buprenorphine as a routine option to all patients: No patient is "too stable" or "too unstable" for LAI buprenorphine. While it is especially helpful for patients with erratic adherence, housing instability, or a preference for injections, any patient can benefit. LAI buprenorphine should be offered as a standard option for everyone. Breakthrough symptoms on LAIs can be managed with flexible strategies: Options include increasing LAI dose, switching formulations, adding short-term sublingual buprenorphine, and addressing underlying causes of symptoms, such as psychosocial factors. Pair medication treatment with additional supports: Even with LAIs, providing behavioral support, psychosocial interventions, and treating co-occurring substance use disorders remain essential for long-term recovery. Schedule frequent visits and encourage behavioral support, group therapy, and psychosocial interventions. Start with just one patient: Clinicians hesitant about LAI buprenorphine should start with a single patient. Find a specialty pharmacy in your area and make the connection. The learning curve is manageable, and the impact is often transformative. 🔗 Resources ASAM 57th Annual Conference Sessions: Enhancing Access with Direct-to-Inject Buprenorphine: Evidence and Implementation Long-Acting Injectable Buprenorphine for Birthing and Parenting People with OUD LAI Buprenorphine in Criminal Justice Settings: Strategies and Tools for Implementation ASAM Clinical Tips Advanced Buprenorphine Video Series: Explore HERE Extended-Release (XR) Buprenorphine Formulations Resource Guide - This resource guide compares two formulations of extended-release (XR) buprenorphine, a long-acting treatment for opioid use disorder (OUD). It highlights differences in dosing, administration, and logistics to support informed clinical decision-making. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids - Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. J Addict Med. 2023;17(6):632-639. doi:10.1097/ADM.0000000000001202 Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal - D'Onofrio G, Herring AA, Perrone J, et al. JAMA Netw Open. 2024;7(7):e2420702. Published 2024 Jul 1. doi:10.1001/jamanetworkopen.2024.20702 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.