Hosp Pediatr. 2026 Jul 17:e2025009094. doi: 10.1542/hpeds.2025-009094. Online ahead of print.

ABSTRACT

BACKGROUND: Illicitly manufactured fentanyl (IMF) is the predominant opioid in the US drug supply and is a major contributor to morbidity and mortality during pregnancy. While prenatal opioid exposure is an established risk factor for neonatal opioid withdrawal syndrome (NOWS), the differential effects of IMF vs other opioids on outcomes are largely unknown. Therefore, we aimed to evaluate the associations between prenatal IMF exposure and fetal, perinatal, and neonatal health outcomes.

METHODS: We conducted a retrospective cohort study of pregnant women with opioid use disorder (OUD) and their infants who were born between January 2024 and December 2024. Maternal and infant participants were stratified into 2 groups based on the opioids, IMF vs medications for OUD (MOUDs), identified on urine drug testing at delivery. Descriptive statistics were used to describe the characteristics of cohort participants, while χ2 and t tests were used to evaluate for differences in outcomes between the groups.

RESULTS: Among 125 infants, 34 were categorized as IMF exposed, and 91 were categorized as MOUD exposed. Fetal growth restriction, preterm birth, and abnormal growth parameters, including low birth weight and very low birth weight, were more frequently identified among IMF- vs MOUD-exposed infants. In addition, IMF-exposed infants were significantly more likely to require neonatal intensive care unit admission, have a longer neonatal hospital length of stay, and require pharmacologic treatment for NOWS.

CONCLUSIONS: Prenatal IMF exposure was associated with significant neonatal morbidity compared with MOUD exposure, highlighting the importance of engagement in maternal substance use treatment during pregnancy to both maternal and neonatal health outcomes.

PMID:42463150 | DOI:10.1542/hpeds.2025-009094

JAMA Netw Open. 2026 Jul 1;9(7):e2623280. doi: 10.1001/jamanetworkopen.2026.23280.

ABSTRACT

IMPORTANCE: Buprenorphine-naloxone and extended-release (XR) naltrexone are both efficacious medications for opioid use disorder that reduce unregulated opioid use and improve opioid cravings and treatment retention. While prior comparative effectiveness studies demonstrated superiority of buprenorphine-naloxone over XR naltrexone for relapse and treatment retention, the comparative effectiveness of both treatments for all-cause mortality and nonfatal opioid overdose outcomes has not been rigorously tested.

OBJECTIVE: To compare the effectiveness of buprenorphine-naloxone vs XR naltrexone after medically managed opioid withdrawal (MMOW) treatment.

DESIGN, SETTING, AND PARTICIPANTS: This observational comparative effectiveness study using a target trial emulation framework leveraged individually linked administrative data from the Massachusetts Public Health Data Warehouse to emulate the protocol of the Extended-Release Naltrexone vs Buprenorphine for Opioid Treatment randomized clinical trial. Participants included adults 18 years or older who were discharged from MMOW in Massachusetts between January 1, 2014, and December 31, 2018. Individuals could meet eligibility criteria more than once. Data were analyzed from December 22, 2023, to January 30, 2025.

EXPOSURES: Initiation of buprenorphine-naloxone or XR naltrexone therapy within 28 days of MMOW discharge.

MAIN OUTCOMES AND MEASURES: Estimated 24-week cumulative incidence of all-cause mortality and nonfatal opioid overdose using inverse probability weighting to adjust for baseline and time-varying confounding.

RESULTS: A total of 36 752 unique individuals who met eligibility criteria were identified and contributed 106 052 MMOW discharge episodes; 79 089 (74.6%) episodes were among individuals who were male and 44 463 (42.1%) were among individuals aged 18 to 29 years. By 28 days after MMOW discharge, initiation of buprenorphine-naloxone was observed among 14 194 discharge episodes (13.4%) and initiation of XR naltrexone was observed among 4734 (4.5%) episodes. The adjusted 24-week cumulative incidence of all-cause mortality after MMOW discharge was 1.4% (95% CI, 1.2%-1.7%) for buprenorphine-naloxone and 1.4% (95% CI, 1.1%-1.8%) for XR naltrexone, corresponding to a risk difference of 0.0 percentage points (pp) (95% CI, -0.4 to 0.4 pp). The adjusted 24-week cumulative incidence of nonfatal opioid overdose after MMOW discharge was 11.6% (95% CI, 10.8%-12.3%) for buprenorphine-naloxone and 13.9% (95% CI, 12.9%-15.0%) for XR naltrexone, corresponding to a risk difference of 2.3 pp (95% CI, 1.2-3.6 pp).

CONCLUSIONS AND RELEVANCE: In this comparative effectiveness study of buprenorphine-naloxone vs XR naltrexone, initiating buprenorphine-naloxone after MMOW discharge was associated with a lower risk of nonfatal opioid overdose at 24 weeks than initiating XR naltrexone, but a similar risk of all-cause mortality.

PMID:42446876 | DOI:10.1001/jamanetworkopen.2026.23280

Subst Use Addctn J. 2026 Jul 10:29767342261463988. doi: 10.1177/29767342261463988. Online ahead of print.

ABSTRACT

BACKGROUND: Opioid treatment programs (OTPs), the only outpatient settings authorized to dispense methadone for opioid use disorder in the United States, often operate within compliance-focused frameworks that do not reflect the complex realities of substance use or the needs of many patients with the evolving opioid crisis. Given their unique infrastructure, OTPs are well-positioned to provide risk reduction services including naloxone, wound care supplies, and other safer use tools.

OBJECTIVES: Describe the implementation and early outcomes of a pragmatic pilot program integrating safer use kit distribution within a large OTP in Western Pennsylvania.

METHODS: Our team worked with the OTP to develop a workflow for safer use kit distribution. Staff offered interested patients a menu of safer use kits from which they could select up to one of each kit type. Prepackaged kits included fentanyl/xylazine test strips and safer injection, smoking, snorting, and wound care supplies. Kit distribution was tracked over a thirteen-month period. Postimplementation, we sampled patient-facing OTP staff on their perspectives of the program.

RESULTS: From November 2024 to November 2025, 643 kits were distributed during 266 encounters with 142 unique patients. High-demand items included test strips and safer smoking kits. Staff reported improved patient engagement, reduced stigma, and stronger therapeutic relationships after implementing on-site kits.

CONCLUSION: Integrating safer use kits into OTPs is both feasible and impactful, demonstrating consistent patient uptake and positive staff perceptions. These findings suggest such models have the potential to support more inclusive, patient-centered care, though future research is needed to determine downstream effects on retention, safety, and clinical outcomes.

PMID:42427185 | DOI:10.1177/29767342261463988

BMJ Qual Saf. 2026 Jul 7:bmjqs-2025-019297. doi: 10.1136/bmjqs-2025-019297. Online ahead of print.

ABSTRACT

INTRODUCTION: Physician burnout is related to patient safety and quality of care. Female physicians face unique challenges which may contribute to higher physician task load (PTL). We investigated the association of gender and PTL, and if gender differences in PTL contribute to burnout, professional fulfilment and intent to leave in medicine.

METHODS: A retrospective observational study using secondary data was conducted in June 2019-June 2021. Physicians at eight large US academic-affiliated medical centres completed a survey assessing PTL using four NASA-TLX items, burnout and professional fulfilment using the Professional Fulfilment Index (PFI), and intent to leave using a standardised single-item measure; demographic items were included. Descriptive statistics characterised the participant sample. χ² tests examined differences across participant characteristics and PTL, PFI and ITL by gender. Logistic regressions assessed associations between PTL and well-being variables. Analysis of indirect association explored the association of PTL and the relationship between gender and well-being variables.

RESULTS: Females had higher mean PTL as compared with males (6.67 (1.82) vs 6.45 (1.96), p<0.001). Higher levels of PTL were associated with lower PFI by PTL quintile (p<0.001), higher burnout by PTL quintile (p<0.001) and greater ITL in the highest PTL quintile (p<0.001). Despite higher burnout and PTL, females had lower odds of ITL than males. Analyses of indirect associations suggested PTL may partially account for the relationship between gender and PFI and burnout, with an opposite-direction (suppression) effect for ITL.

CONCLUSIONS: Higher mean PTL scores were observed in females compared with males. Findings suggest that both gender-specific and gender-agnostic interventions for addressing cognitive burden may be relevant for supporting well-being for all physicians.

PMID:42414091 | DOI:10.1136/bmjqs-2025-019297

Subst Abuse Treat Prev Policy. 2026 Jul 3. doi: 10.1186/s13011-026-00746-1. Online ahead of print.

ABSTRACT

BACKGROUND: The evolving U.S. drug market has fueled a public health crisis with rising drug use-associated morbidity and mortality, revealing a mismatch between current abstinence-based addiction care and the needs of people who use drugs (PWUD) to access evidence-based harm reduction services (HRS). Co-locating HRS into outpatient clinics could reduce mortality and improve clinical outcomes. We investigated barriers and facilitators of HRS implementation through kit distribution at three heterogenous outpatient addiction clinics using pre- and post-implementation focus groups.

METHODS: Using a qualitative description approach, we conducted 1-hour virtual focus groups and individual interviews with clinic staff and providers both pre- and post-implementation of kit distribution. Interview guides were based on the Consolidated Framework for Implementation Research to assess anticipated and actual implementation barriers and facilitators. Interviews were analyzed using thematic analysis.

RESULTS: Five providers and six staff participated in pre-implementation data collection. Dominant themes pre-implementation included participant enthusiasm for HRS integration and anticipated barriers of personal knowledge and external stigma against PWUD. Six providers and five staff participated post-implementation. Participants reported successful kit implementation with few actual barriers, though external stigma at the individual, health system, and community levels, along with issues related to patient use and interactions with child protective services, law enforcement, and pharmacies, occasionally disrupted the process. The lack of sustainable funding for supplies and labor emerged as a primary concern for long-term sustainability, with clinics actively seeking alternative funding sources.

CONCLUSIONS: Implementation of HRS in outpatient addiction clinics was well-received by providers and staff and supported by pre-implementation trainings, site champions, and favorable implementation environments. Further efforts are needed to reduce stigma in the greater community and achieve sustainable funding for HRS.

PMID:42400068 | DOI:10.1186/s13011-026-00746-1

Harm Reduct J. 2026 Jul 1. doi: 10.1186/s12954-026-01492-0. Online ahead of print.

ABSTRACT

INTRODUCTION: People who use drugs (PWUD) in the U.S. often face barriers to accessing harm reduction, social, and medical services, including fragmented systems and limited access to locally relevant, usable information. A digital harm reduction support tool (DHRST) that identifies clients’ needs and matches them to available community resources may help address these barriers. We examined the feasibility and acceptability of a DHRST among PWUD, as well as its potential role in supporting safer practices and improving engagement with services.

METHODS: We recruited a convenience sample of 37 clients from a community-based harm reduction organization to participate in semi-structured interviews. Participants were ≥ 18 years old, English-speaking, and able to provide informed consent. Interviews explored perceptions of the feasibility, acceptability, and potential uses of a DHRST. Data were analyzed using thematic analysis.

RESULTS: Four primary themes emerged from our data: (1) participants viewed a DHRST as a valuable tool for navigating fragmented and locally specific information about harm reduction, social, and healthcare services; (2) participants perceived the tool as a means of enhancing safety in an increasingly unpredictable drug supply through access to real-time, peer-generated information and alerts; (3) participants expressed concerns about privacy, surveillance, and the potential unintended consequences of sharing sensitive information; and (4) participants emphasized that feasibility would depend on accessibility, including device access, digital literacy, and the availability of multiple platforms for engagement. Overall, participants expressed strong enthusiasm for the potential value of a DHRST despite concerns regarding implementation and information security.

CONCLUSIONS: Findings suggest that a DHRST is both acceptable and potentially valuable for supporting harm reduction among PWUD, particularly as a means of improving access to locally relevant information. However, its effectiveness will depend on careful attention to structural constraints, privacy and data governance, and the broader risk environment in which information-sharing occurs. These findings support continued development of DHRSTs while emphasizing the need for user-centered and context-sensitive design.

PMID:42381009 | DOI:10.1186/s12954-026-01492-0

Am J Ind Med. 2026 Jun 28. doi: 10.1002/ajim.70108. Online ahead of print.

ABSTRACT

BACKGROUND: Rideshare driving has become a common occupation within the emerging gig and platform economies. Despite offering a high degree of scheduling flexibility, rideshare driving provides little employment stability, an unstable income, and minimal employment benefits. This precarity, combined with the use of algorithmic labor management to guide drivers’ actions, has garnered attention for its potential impacts on these workers’ health.

METHODS: To examine rideshare drivers’ perspectives of their work and its implications for their well-being, this exploratory study examined posts (n = 1034) to the digital platform Reddit in the year 2024 using thematic analysis.

RESULTS: Themes indicated that workers experience financial precarity but also appreciate the flexibility of rideshare driving. Drivers are also aware of the algorithms that guide their work and, at times, feel that these prevent them from increasing their earnings. Drivers posted about experiences with passengers-both positive and negative-while also discussing the mental stressors of ride sharing and concerns about their physical safety on the job.

CONCLUSIONS: These findings underscore the varied experiences rideshare drivers encounter in their workplace, while highlighting potential implications for their physical and mental well-being. Understanding these first-hand accounts may inform efforts to improve the well-being of platform-based workers.

PMID:42365446 | DOI:10.1002/ajim.70108

Addiction. 2026 Jun 22. doi: 10.1111/add.70504. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Individuals who engage in illicit or nonmedical opioid use may have elevated risk of health and social consequences, including progression to opioid use disorder (OUD). Preventive interventions to reduce this risk are lacking. This trial tested the impact of a primary care-integrated collaborative care approach for reducing risky opioid use, defined as nonmedical use of prescription opioids or any use of illicit opioids.

DESIGN: Cluster-randomized controlled trial randomized primary care providers (PCPs) and their patients into the Subthreshold Opioid Use Disorder Prevention (STOP) intervention or enhanced usual care (EUC).

SETTING: Primary care clinics at 5 U.S. sites.

PARTICIPANTS: PCPs and their patients were recruited January 2021-May 2023. A total of 119 PCP clusters (STOP = 48, EUC = 51) and 202 patients (STOP = 88, EUC = 114) enrolled. Eligible patients were adults (≥18 years) having current risky opioid use, without moderate-severe OUD. Patient participants were majority female (63.4%), white (70.8%) and non-Hispanic (96.5%), with a mean age of 55.7 [standard deviation (SD) = 12.7] years. At baseline, 63.4% of participants had moderate-severe pain (Brief Pain Inventory) and below average physical (79.2%) and mental (62.4%) health (SF-12).

INTERVENTIONS: The STOP collaborative care intervention consisted of brief advice from the PCP about reducing risky opioid use, meetings with a clinic-embedded nurse care manager over 12 months and remote health coaching (2-6 sessions). Both groups received primary care treatment as usual and overdose risk reduction materials.

MEASUREMENTS: The primary outcome was total days of risky opioid use, recorded from 6 monthly electronic surveys. A key secondary outcome was moderate-severe OUD at 6 and 12 months.

FINDINGS: A total of 77 (87.5%) STOP and 107 (93.9%) EUC participants completed the 6-month assessment period. The primary outcome analysis used the Intention-to-Treat sample with multiple imputations of missing data. Mean days of risky opioid use at 180 days were lower in STOP than EUC [12.2 (SD = 27.73) vs. 15.5 (SD = 32.64)]; the difference between groups adjusted for baseline risky opioid use was not statistically significant (rate ratio 0.95, 95% confidence interval = 0.52-1.74). One STOP participant (1.1%) and 13 EUC participants (11.4%) developed moderate-severe OUD at 6 months, and 3 (3.4%) STOP and 6 (5.3%) EUC participants had moderate-severe OUD at 12 months (P < 0.001).

CONCLUSIONS: This cluster-randomized controlled trial did not find evidence that the STOP intervention for reducing risky opioid use produced greater reductions over 6 months compared with enhanced usual care, though fewer intervention participants progressed to moderate-severe opioid use disorder. Patients had a high burden of pain and comorbidities that may present challenges to reducing opioid use.

PMID:42331724 | DOI:10.1111/add.70504

Harm Reduct J. 2026 Jun 17. doi: 10.1186/s12954-026-01486-y. Online ahead of print.

ABSTRACT

BACKGROUND: As xylazine-adulterated opioids become more prevalent in the U.S., people who use drugs (PWUD) face growing risks from sedation, withdrawal, and wounds. This study explores PWUD perceptions on recognizing xylazine exposure including its physical effects and clinical harms and how these factors shape their drug use practices.

METHODS: In August 2023, we surveyed adult PWUD clients reporting at least one past-year drug use-related wound across three Massachusetts syringe service programs with high xylazine prevalence. We compared demographics, drug use factors, physical effects, and clinical symptoms between those with and without self-reported past-90-day xylazine exposure and conducted content analysis of open-ended responses.

RESULTS: Of the 171 respondents, 80% (n = 136) reported past-90-day xylazine exposure. The majority of respondents were male, white, non-Hispanic, and aged 36-45 years, with no significant differences by xylazine exposure. Xylazine-exposed participants commonly reported sedation (77%), loss of consciousness (52%), and wounds (91%). Most participants were afraid and frustrated, seeing xylazine as an unwanted contaminant but were often unable to avoid it due to financial constraints, withdrawal symptoms, and limited alternative options.

CONCLUSION: Syringe service program clients in Massachusetts commonly reported xylazine-adulterated fentanyl exposure, recognized through heavy sedation and skin wounds. Their experiences highlight the urgent need for real-time xylazine detection, safer supply, overdose and sedation risk mitigation, and improved wound prevention and care.

PMID:42310644 | DOI:10.1186/s12954-026-01486-y

J Am Pharm Assoc (2003). 2026 Jun 17:103469. doi: 10.1016/j.japh.2026.103469. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with opioid use disorder encounter challenges obtaining buprenorphine (BUP) at pharmacies, increasing their risk of treatment non-adherence and illicit drug use.

OBJECTIVES: The purpose of this quality improvement (QI) initiative was to implement and evaluate a multi-component intervention to ensure continuous BUP access.

METHODS: Using a quasi-experimental study design, the initiative was developed and a convenience sample was recruited from an outpatient BUP treatment program and a pharmacy affiliated with the West Virginia University health system between November 20, 2023, to November 29, 2024. The QI intervention consisted of education, use of pharmacy-integrated electronic medical record (EMR), BUP delivery and adherence support and/or assistance with BUP dispensing. Participants selected the intervention or wait-list control group based on their choice of pharmacy. The intervention was offered to the intervention group over a 3-month period. Proportion of days covered was the primary outcome measure for continuous BUP access. Clinical data were extracted from participants’ EMR and electronic satisfaction surveys were administered to all participants following the intervention.

RESULTS: Study participants included 56 patients prescribed sublingual BUP, 14 pharmacy staff, and 19 clinic staff. Nine patient participants (16.07%) received medication delivery, and 8 patient participants (14.28%) received medication adherence support and/or assistance with BUP dispensing. There was no significant difference in the mean proportion of days covered (PDC) for BUP between the intervention (97.31%) and control group (94.90%) (p=0.32). Compared to the control group, the intervention group had lower retention rates (76.92 % vs. 97.37%, p=0.02) and was more likely to report satisfactory waiting time to receive BUP (X²=4.85; 100 % vs. 64.50%, p=0.028).

CONCLUSION: The intervention was successfully implemented and highly rated; however, it did not significantly increase the PDC of BUP. Challenges with BUP dispensing persist and future research addressing these multi-level barriers are urgently needed.

PMID:42309279 | DOI:10.1016/j.japh.2026.103469