J Pain Symptom Manage. 2026 Aug 19:S0885-3924(26)00954-1. doi: 10.1016/j.jpainsymman.2026.08.011. Online ahead of print.

ABSTRACT

CONTEXT: Hospice and palliative medicine (HPM) clinicians increasingly care for patients with serious illness and prolonged opioid exposure, yet often report limited training managing consequences like opioid misuse or opioid use disorder (OUD). Little is known about core addiction skills training in HPM physician fellowships.

OBJECTIVES: To describe current training in core addiction skills for HPM fellows, identify barriers to curricular expansion, and characterize fellowship program director (PD) perspectives and priorities.

METHODS: Cross-sectional national survey of PDs from ACGME-accredited HPM fellowships in the United States assessing core addiction skills training, PD perspectives, and curricular challenges and priorities.

RESULTS: Of 160 eligible programs, 79 PDs responded (49.4%). Most PDs rated addiction training as highly relevant (86%) and important (75%) to HPM practice. PDs perceived that fellows have low confidence with opioid misuse or OUD, despite commonly encountering such patients. Most programs offered limited training (2-3 hours), though many provided electives. Fewer than 20% of programs had faculty with formal addiction training, and 25% reported no faculty with buprenorphine experience. The most frequently cited barriers to curricular expansion were limited faculty expertise in addiction and buprenorphine, and competing curricular priorities. While foundational skills were commonly addressed, PDs identified curricular development priorities including: buprenorphine use, pain management in OUD, and motivational interviewing.

CONCLUSION: Despite broad recognition of the importance of core addiction skills, a shortage of faculty expertise constrains education in HPM physician fellowships. Scalable, technology-enabled, shared curricular approaches may help expand access to expertise and better align training with clinical demands.

PMID:42617988 | DOI:10.1016/j.jpainsymman.2026.08.011

Pregnancy (Hoboken). 2026 Mar 22;2(2):e70274. doi: 10.1002/pmf2.70274. eCollection 2026 Mar.

ABSTRACT

INTRODUCTION: The emergence of xylazine, a veterinary alpha-2 and kappa opioid receptor agonist, as an adulterant in illicitly manufactured fentanyl has created new challenges and risks for pregnant people who use unregulated opioids. Xylazine test strips (XTSs) have been proposed as a harm reduction strategy, but their use has not been studied among pregnant and postpartum populations. The goals of this study were to assess the feasibility, acceptability, and efficacy of a novel Perinatal XTS intervention aimed at reducing xylazine exposure and associated harms.

METHODS: Pregnant and postpartum women with opioid use disorder and high risk of ongoing unregulated opioid use were recruited from inpatient units of a high-volume maternity hospital in western Pennsylvania. Participants engaged in a standardized educational session about xylazine and XTS and then were given five XTS kits. Over a 2-month period, participants were asked to complete a real-time survey when they used an XTS to report test results and any associated drug use behavior change. All participants were asked to participate in an end-of-study survey and a semi-structured interview about their experiences with Perinatal XTS.

RESULTS: A total of 50 participants were enrolled, completed the education session, and accepted the XTS kits. Most participants were concerned about the potential impacts of xylazine on pregnancy and neonatal outcomes. Seventeen participants submitted a total of 71 real-time surveys after using XTS to test drug samples. In the majority of cases, a positive result prompted behavioral change. Qualitative interviews with participants revealed six major themes: (1) Xylazine and XTS education was highly acceptable. (2) Desire for additional education related to xylazine. (3) XTS distribution and use were highly acceptable. (4) Impact of XTS on behavior change varied based on participant circumstances. (5) Concerns related to xylazine’s impact on maternal health and treatment. (6) Concerns related to xylazine’s impact on fetal and neonatal health.

CONCLUSION: Findings from this pilot study demonstrate that Perinatal XTS, a harm-reduction intervention combining xylazine and XTS education and XTS kit distribution, is highly feasible to deliver, is acceptable among pregnant and postpartum women cared for in an obstetric healthcare setting, and has the potential to reduce risk-related behaviors.

PMID:42596917 | PMC:PMC13344234 | DOI:10.1002/pmf2.70274

JAMA Intern Med. 2026 Aug 10. doi: 10.1001/jamainternmed.2026.3788. Online ahead of print.

NO ABSTRACT

PMID:42574008 | DOI:10.1001/jamainternmed.2026.3788

Psychiatr Serv. 2026 Aug 6. doi: 10.1176/appi.ps.20250157. Online ahead of print.

ABSTRACT

OBJECTIVE: The COVID-19 pandemic exacerbated health disparities and increased alcohol use and its health consequences. Although prepandemic research identified racial and ethnic disparities in receipt of alcohol use disorder treatment, few studies have described postpandemic disparities or have assessed the role social determinants of health (SDOHs) may play in these inequities. The authors examined how rates of treatment for alcohol use disorder differ by race and ethnicity, SDOHs, and at the intersection of both.

METHODS: In this cross-sectional analysis, the authors used a nationally representative sample of 5,785 U.S. adults with past-year alcohol use disorder from the 2023 National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression models were used to estimate the probability of any past-year alcohol use disorder treatment overall, by the intersection of race and ethnicity with 20 SDOH subcategories, and across treatment settings.

RESULTS: Only 9.6% of adults with alcohol use disorder in the NSDUH received any treatment in 2023. Compared with other racial and ethnic groups, non-Hispanic Black or African American adults had the lowest probability of receiving treatment for alcohol use disorder overall and in the stratified analyses of nine of 20 SDOH subcategories.

CONCLUSIONS: These findings highlight significant disparities in the receipt of treatment for alcohol use disorder among non-Hispanic Black or African American adults, generally concentrated within the more vulnerable SDOH categories. These results underscore a critical need for clinically and culturally nuanced policies and practices tailored to specific populations with health disparities.

PMID:42557603 | DOI:10.1176/appi.ps.20250157

Am J Prev Med. 2026 Jul 30:108537. doi: 10.1016/j.amepre.2026.108537. Online ahead of print.

ABSTRACT

INTRODUCTION: A 2019 Medicare opioid safety policy limited initial opioid duration to 7 days and long-term daily dosage to 90 morphine milligram equivalence (MME). Because effective pain management may vary by rurality, this study examined whether the policy differentially affected opioid prescribing among rural versus urban beneficiaries with disabilities.

METHODS: Deidentified claims data was used to gather a rolling cohort of Medicare Advantage beneficiaries with disabilities ages 18 to 64 from 2016 to 2021. Comparative interrupted time series were used in 2025 to analyze rural-urban differences in the duration and dosages of opioid fills for new-to-opioid beneficiaries, the target of the 7-day limit (N = 526,019 person-months), and the number of high-dosage episodes for long-term opioid beneficiaries, the target of the 90-MME limit (N = 3,312,161 person-months).

RESULTS: Despite significant reductions in initial opioid duration for both groups, the 7-day limit effect on initial opioid duration weakened over time (trend change: 0.17 [98.75% CI 0.04 to 0.30]) in the rural relative to the urban group. By the end of the study period, the rural group experienced 3.8 percentage points more initial opioid fills exceeding the 7-day limit (95% CI 0.4 to 7.3) than the urban group. Furthermore, the total dosage prescribed in subsequent fills among rural beneficiaries was 27.97 MME (95% CI -52.19 to -3.75) less than urban beneficiaries by the end of the study period. The rural and urban groups responded similarly to the 90-MME limitation.

CONCLUSIONS: Rural relative to urban new-to-opioid beneficiaries with disabilities experienced a weakened effect on initial opioid duration after Medicare’s 7-day limit, while receiving declining dosage in follow-up opioid fills, suggesting potential disparities in access to follow-up opioid prescriptions for rural versus urban beneficiaries with disabilities. Policymakers may consider more flexible opioid regulations and attention to alternative pain management for rural Medicare beneficiaries.

PMID:42532454 | DOI:10.1016/j.amepre.2026.108537

J Pain. 2026 Jul 29:106313. doi: 10.1016/j.jpain.2026.106313. Online ahead of print.

ABSTRACT

The aims of this study were to characterize symptom clusters and examine the influence of social determinants of health (SDOH) on symptom cluster membership among people receiving maintenance hemodialysis and experiencing chronic pain. This study utilized baseline data collected from the 643 patients enrolled in the HOPE Consortium Trial designed to test the efficacy of an intervention to reduce chronic pain. Latent profile analyses were performed to characterize symptom clusters. SDOH variables were collected using self-report and the Census Geocoder. Five distinct clusters of symptoms were identified including (1) moderate levels of anxiety, (2) average level of all symptoms, (3) low levels of all symptoms, (4) low levels of anxiety, and (5) high levels of all symptoms. When compared to the symptom cluster with average level of symptoms, higher everyday discrimination scores were associated with higher odds of membership in the clusters reflecting moderate levels of anxiety and high levels of all symptoms. Greater residential segregation was associated with higher odds of being in the low anxiety cluster; and greater income inequality was associated with higher odds of membership in the moderate level anxiety symptom cluster. Multi-level interventions targeting discrimination and those living in areas with the greatest income inequality are warranted to reduce symptom burden and improve quality of life in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov #NCT04571619 PERSPECTIVE STATEMENT: Social determinants of health (SDOH) such as discrimination and income inequality were associated with higher anxiety while segregation resulted in lower levels of anxiety reflecting the complex relationship between SDOH and mental health. Multi-level interventions targeting discrimination and income inequality are warranted to reduce symptom burden in this patient population.

PMID:42526778 | DOI:10.1016/j.jpain.2026.106313

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