The Neurobiology of Addiction
Editor A Note from the
I am thrilled to be part of the second issue of PSAM Review. As a co-editor, I want to begin with heartfelt thanks to everyone who contributed—writers, editors, organizers, and supporters alike. Your passion, dedication, and thoughtful contributions have made this issue possible.
This publication remains close to my heart, not only because it is built by and for physicians in Addiction Medicine/Psychiatry, but because it represents something even greater: the full humanity of our profession. The process of bringing a journal to life reminds me of my marathon experiences. I’ve often said, “Anyone can run a marathon. It takes a special kind of person to run two—and a really special kind of person to keep running them over and over.” Sustained effort, endurance, and commitment are required not just in long-distance running, but in any creative or professional endeavor we hope to build into something lasting. The PSAM Review is our collective marathon, and I’m excited to see how we continue to grow with each stride forward.
As we move into the planning stages for future issues, I want to take a moment to clarify our editorial direction in hopes of encouraging more submissions and ensuring they align with the publication’s goals.
The PSAM Review is not a peer-reviewed scientific journal. It was never intended to compete with academic journals, nor do we aspire to replicate what’s already being done well elsewhere. While we are open to articles that touch on clinical research or scientific studies, authors should be aware that publishing a full research article here may disqualify it from future publication in an academic journal. If you have original data or a study you are proud of, consider instead submitting a summary, reflection, or plain-language review of your work for the PSAM Review—and reserve the full manuscript for a journal that can better disseminate an academic publication.
This flexibility opens the door to something truly special: a place where we can reflect on the meaning of our work, not just the mechanics of it. What sets the PSAM Review apart is that it treats physicians not just as providers, but as full human beings—people with stories, hobbies, memories, humor, failures, growth, and creativity. We want to hear from the whole person, not just the doctor in a lab coat.
We invite you to share your personal stories, essays, or reflections—particularly those that illuminate life inside and outside of medicine. What’s it like to navigate the world as a physician in Addiction Medicine? How do you recharge your spirit? What passions sustain you
outside of clinic hours? What moments have stuck with you through the years—joyful or heartbreaking?
We’re also deeply interested in submissions inspired by the arts and humanities. Do you have a poem you wrote? A personal narrative that reads like a short story? A photo you’re especially proud of? A painting that helps you process or escape? These are not just welcome— they’re encouraged. Please note, though, that if you’re submitting visual work, we ask that you send us a highresolution image file of the piece (not the original) and we’ll coordinate with our publisher to ensure the best format.
You don’t have to be an experienced writer or professional artist. If your piece comes from the heart and reflects a genuine perspective, it will find a home here. Our team is more than happy to work with contributors on editing and formatting as needed.
To help streamline the process and minimize any confusion, here are our general submission guidelines:
• Word count: Articles and stories should aim for no more than 2,000 words. This is a soft cap; if you’re a bit over or under, that’s fine—we’re looking for approximate length, not perfection.
• Format: Please submit all written work as a Word document. If your piece includes a photo or other visual element, feel free to reach out in advance to discuss file format and layout.
• Tone: Keep in mind that our readers are your peers. Write with warmth, honesty, and clarity. Whether your submission is serious, humorous, reflective, or informative, we appreciate writing that invites connection.
I hope you enjoy reading this second edition of the PSAM Review as much as we enjoyed putting it together. The articles, photos, and the summary of the recent ASAM conference contribute to a broader portrait of who we are—not just as specialists in Addiction Medicine/Psychiatry, but as multidimensional human beings.
We are committed to making this publication a space where voices can be heard, creativity can flourish, and meaningful connections can be made across our professional community. Our goal is to grow this publication issue by issue, just as a runner builds strength mile by mile.
Please consider contributing to future editions. Make your submission personal, thoughtful, and unique—and don’t be afraid to share something a little unexpected. Those are often the most memorable pieces.
William Santoro, MD, FASAM, DABAM
1.
President’s Address
by James R. Latronica, DO, DFASAM
It’s been an honor to be a member of PSAM’s board since 2021, and becoming President is an even greater honor—one I honestly was not expecting. I want to discuss some things we’ve been doing since 2021 and explain where we see this chapter going.
You can find our website at psam-asam.org, and we also have Facebook and Instagram pages. The website hosts a slide deck of our legislative initiatives and actions dating back to 2021.
We have a new Board Administrator, Kayla Musolino, who will be our main member-facing staff person. We continue to receive wonderful help from the Pennsylvania Medical Society in terms of communicating with ASAM and other high-level administrative functions.
Past President Dr. Bill Santoro has spearheaded a beautiful and eclectic publication called the PSAM Review which is published twice per year at this time. The digital version is freely available on the website. The Review accepts a wide variety of submissions—if you’re not sure if we’d publish it, please send it in as we probably will! We accept submissions on a rolling basis so don’t worry about a specific time frame.
Immediate Past President Dr. Kristin Van Zant remains indefatigable in her efforts to coordinate our annual symposium. We have now had two symposia in a row, and attendance at this year’s in March was double compared to the one held in 2024. At some point we are considering moving to a live/remote hybrid model, so stay tuned! Next year’s symposium is tentatively scheduled for Saturday 3/7/26.
Overall, we now have four committees: Public Policy, Education (which includes symposium planning), Advanced Prescribing Practitioners (APP), and PSAM Review. They meet every other month, and we will soon be moving to a system where all the committees meet on the same night of the month and move into breakout rooms for ease of planning and increased communication. The PSAM Review Committee is the newest and could use the most volunteers, but all the committees currently have open spots, so please reach out if you’d like to join a committee!
Dr. Rob Tessier has become the Chair of the Public Policy Committee, and the PPC continues its work on crafting a statement on the legalization of cannabis for adult use. We will be using ASAM’s previous statement as a guideline while adding Pennsylvania-specific suggestions, such as minimizing advertising,
robust and guaranteed investment in public health, and oversight by an appropriate arm of the state government.
Finally, I’d like to take a moment to discuss advocacy efforts during unusual times. Given that this is the President’s message, please note that this is an editorial portion and does not necessarily reflect the views of ASAM, PSAM, or either of its boards. While we are a state chapter and our focus is more limited
Put plainly, arbitrary and capricious changes to our foundational health institutions like NIH and SAMHSA or the potential gutting of public insurance programs like Medicaid are frightening, awful things that we should not accept.
in scope than ASAM, I think I’d be remiss if I didn’t mention the current political climate, especially since federal policy often “rolls downhill.” Put plainly, arbitrary and capricious changes to our foundational health institutions like NIH and SAMHSA or the potential gutting of public insurance programs like Medicaid are frightening, awful things that we should not accept. As we push back vigorously against these changes, we will have to wrestle with what resistance looks like in the setting of continuing to advocate for long-overdue change.
Continuing to support bills like the Modernizing Opioid Treatment Access Act (MOTAA) is clearly still part of ASAM’s national strategy. Given how the levers of the executive branch are currently being used, there may also be an opportunity to “de-regulate” methadone more broadly via the same type of Executive Orders which have been used, as noted above, for destructive purposes. Should we completely disengage and not deal with this administration at all? Should we use available levers in dark times to try to benefit our patients? I’ll admit that personally, I am conflicted and will continue to be over the course of this administration. I don’t think any person or group has a good answer because any answer we have is imperfect in one sense or another. I don’t have a call to action here, I just wanted to put on paper what I’m sure a lot of our members are feeling.
But no matter what, remember that better things are possible, and we should always be ready to fight for them.
ADVOCACY
for the CCBHC and ICWC Model of Care
by Kristin Van Zant, M.D., FASAM, DLFAPA, Immediate Past President PSAM, Medical Director for CCMBH and ICWC, NET-Centers, and Lisa Kramer, Vice President for Integrated Health Services, NET-Centers
The statistics are clear. Substance use is highly comorbid with behavioral health and physical health complications. Mental health disorders frequently co-occuring with substance use disorders include anxiety, depression, post-traumatic stress disorder, psychosis, and personality disorders. Substance use can be complicated by poor nutrition, higher cancer risks, and chronic pain. People who inject drugs are at higher risk of Hepatitis B and C,
FQHCs are an enormous and critical resource, providing an array of vital treatments including primary care, dental care, and behavioral health treatment, as well as substance use support.
HIV, and tuberculosis in addition to sexually transmitted diseases (1). People with mental illness die on average 25 years earlier than peers with higher prevalence of tobacco use and metabolic syndrome. For individuals with high acuity health needs, there may be barriers to accessing care such as transportation, insurance, treatment availability and pharmacy deserts. Having access to funded integrated health supports is critical in supporting individuals on their health and recovery journeys.
Serving vulnerable and underserved communities has been a key feature of both Certified Community Behavioral Health Clinics (CCBHCs) and Federally Qualified Healthcare Clinics (FQHCs). The Federally Qualified Health Center (FQHC) program was established under the Omnibus Budget Reconciliation Act of 1989 with the goal of enhancing care to underserved areas through special payment arrangements with Medicare and Medicaid. FQHCs are an enormous and critical resource, providing an array of vital treatments including primary care, dental care, and behavioral health treatment, as well as substance use support. Behavioral health and substance
treatment sub-teams can live within an FQHC, providing a continuum of supports.
In the last 10+ years, the CCBHC concept and national implementation has been a critical lift in the provision of high-quality integrated care to vulnerable communities. CCBHCs are designed to serve anyone who walks through the door, regardless of their diagnosis and insurance status. The passage of the Excellence in Mental Health Act of 2014 led to the implementation of the concept through the 2017 Section 223 CCBHC Medicaid Demonstration program. 67 CCBHCs were established in eight states with an enhanced Medicaid reimbursement rate. CCBHCs receive funding based on a prospective payment system (PPS), which provides more flexibility for providers to meet the needs of their clients.
CCBHCs are required to provide nine services including
1. Crisis services
2. Screening assessment and diagnosis
3. Patient-centered treatment planning
4. Outpatient mental health
5. Primary care screening and monitoring
6. Case management
7. Psychiatric rehabilitation
8. Peer support
9. Services for veterans and members of the armed forces
What started as the original two-year, 8-state initiative in the expansion of American’s access to communitybased mental health and addiction care has expanded to funding of over 500 CCBHCs across the country. From the beginning, Pennsylvania has been an active participant. Pennsylvania took the CCBHC concept and created a statespecific pilot program, the Integrated Care and Wellness Center (ICWC), to test and refine the CCBHC for later,
broader implementation through the Section 223 demonstration, and by 2019 transitioned to the managed care directed payment program known as the Integrated Community Wellness Centers (ICWC). The CCBHC and ICWC model emphasize the provision of both physical health and mental health (6).
The Philadelphia community has both an Integrated Care and Wellness Center (ICWC) and CCBHC within the non-profit agency The NET-Centers. Individuals living with poverty, housing insecurity, severe mental illness, severe substance use, and an array of physical health complications are provided services. Lisa Kramer, Vice President for Integrated Health Services at NET-Centers, oversees operations of both the ICWC and CCBHC. Though services are open to individuals across the city, the majority of members reside in the North Philadelphia, Frankford, and Kensington neighborhoods, zip codes with elevated opioid overdoses, significant poverty, gun violence and other social determinants of poorer health outcomes. These areas have been the epicenter of a complex, dangerous, and rapidly evolving drug supply.
Members have same-day access to intake, assistance with insurance, crisis management, and mental health resources. There is easy referral access to Certified Peer Supports and Case Management teams. Services include a Mental Health Outpatient team as well as a Substance Use treatment team. Coming out of jail and need a Buprenorphine prescription to avoid relapse and overdose? There is same-day access to care. There are also services across the age spectrum with child and juvenile services and access to Child Psychiatrists and Child Psychiatry fellows. Having a relationship with an academic center enables placement of PGY3 Psychiatry Residents and Addiction Psychiatry fellows. Case Management includes a substance use specific case management team. Certified Peer Specialists provide peer supports and WRAP (Wellness Recovery Action Plan) groups.
Health is immediately addressed with screenings and access to an FQHC that comes onsite monthly. The Physical health office, led by Nursing expert Saleemah Hodges, provides the health screens, metabolic screening, harm reduction supports including Naloxone, test strips, pregnancy tests, diabetes education and oversight, and access to STD testing, tobacco recovery resources, and phlebotomy. There is monitoring of member medical and psychiatric data including hospitalizations through the Health Exchange, long-acting injectables including Naltrexone, Buprenorphine, Paliperidone, Risperdone, Haloperidol, and Aripirazole. With the recent REMS changes, Clozapine is now more easily available
Akera Young is the Program Director for the ICWC’s Substance Use services. These services include access to Medications for Opioid use Disorder (MOUD) as well as MAT, an OBOT, a
team of Counselors leading individual sessions and groups, and access to CPS and Case Management supports. One highlight of Ms. Young’s expertise is her professional connection with Philadelphia’s Drug Treatment Court judges and staff. Ms. Young attends DTC twice weekly and provides critical linkage for individuals with legal charges, probation, and who also have substance use and mental health issues and are able to be diverted to treatment at the ICWC and CCBHC rather than automatically incarcerated. She also oversees the Adolescent OP program that was recognized by the Philadelphia DTC for exceptional Service for Juvenile Treatment Court and Juvenile Probation.
the continuum of care for individuals needing critical health resources. ASAM’s April 25, 2025 release of the newest policy, “Ensuring the Financial Sustainability of Addiction treatment Services in the United States,” is a call for action in the advocacy for the sustainability of addiction services. As legislators parse the need for and cost of federally funded programs, let’s support the preservation of life-sustaining integrated health care services in communitybased programs such as CCBHCs.
My sense of purpose and the driving force that keeps me going, even when things get tough, is having grown up in an environment and seeing substance use with my immediate and extended family.
— Denisha Van-Buren, Program Director
NET’s CCBHC is located at Broad and Lehigh at the confluence of Kensington and North Philadelphia and is a newer SAMHSA-funded program with program offerings similar to the ICWC. Program Director Denisha Van-Buren has had years of experience serving vulnerable communities and for her there is a personal mission. “I do the work to make a positive impact in the lives of individuals struggling with their mental health and substance use. My sense of purpose and the driving force that keeps me going, even when things get tough, is having grown up in an environment and seeing substance use with my immediate and extended family. The work has become personal for me since our systems often fail and people have trouble accessing care.”
Often the ICWC and CCBHC teams must drop everything and shift activities when people are brought by the Sheriff directly from jail and their handcuffs removed. The team must quickly provide an intake assessment, connect with insurance, establish housing, screen for any health acuity, and acutely provide Buprenorphine and other mental health medications. Both teams face challenges with assessing and treating people who are actively using a complicated Philadelphia drug supply (Xylazine, Medetomidine, Kratom, and other novel and synthetic substances). The teams have also faced challenges with safety and working in neighborhoods with active gang and gun violence.
ASAM’s 56th 2025 conference in Denver had timely presentations on the creation and preservation of a continuum of addiction recovery services. Taking those thoughts a step forward, the 500+ CCBHCs across the country are certainly important resources in
References:
1. WHO https://www.who.int/teams/ global-hiv-hepatitis-and-stis-programmes/ populations/people-who-inject-drugs
2. Saloner B, Li W, Flores M, Progovac AM, Lê Cook B. A Widening Divide: Cigarette Smoking Trends Among People With Substance Use Disorder And Criminal Legal Involvement. Health Aff (Millwood). 2023 Feb;42(2):187-196. doi: 10.1377/ hlthaff.2022.00901. PMID: 36745833; PMCID: PMC10157835.
3. Chang CH, P W Bynum J, Lurie JD. Geographic Expansion of Federally Qualified Health Centers 2007-2014. J Rural Health. 2019 Jun;35(3):385-394. doi: 10.1111/jrh.12330. Epub 2018 Oct 23. PMID: 30352132; PMCID: PMC6478577.
4. Staloff J, Cole MB, Frogner B, Sabbatini AK. National and State-Level Trends in Mental Health and Substance Use Disorder Services at Federally Qualified Health Centers, 2012-2019. J Community Health. 2024 Apr;49(2):343-354. doi: 10.1007/ s10900-023-01293-7. Epub 2023 Nov 21. PMID: 37985556.
5. National Council for Mental Well-Being; https:// www.thenationalcouncil.org/program/ccbhc-successcenter/ccbhc-overview/#:~:text=A%20Certified%20 Community%20Behavioral%20Health,their%20 diagnosis%20and%20insurance%20status.
6. National Council For Mental Well-Being; the CCBHC Success Center
7. ASAM Public Policy Statement “Ensuring the Financial Sustainability of Addiction treatment Services in the United States”, Adoption date: April 23, 2025
Bridging the Gaps Beyond the Classrooms and Clinics
by Olapeju Simoyan, MD, MPH, BDS, FAAFP, DFASAM, FAMWA
“Bridging the Gaps” is a collaboration between several academic health centers and community organizations in Pennsylvania and New Jersey.
In this issue, medical student Josette Graves shares her experience during the summer between her first and second years of medical school. As part of Drexel College of Medicine’s “Bridging the Gaps” program, she spent time at an addiction treatment center and learned much more about addiction than she did in the classroom. Josette writes that the experience allowed her to “deconstruct the stigma of addiction.” In addition to learning about an integrated approach to health care, including incorporating smoking cessation and oral health into substance abuse treatment, she learned the importance of building trust and celebrating small wins with patients.
The patient stories in Ms. Grave’s essay remind us that our patients are human beings, just like the rest of us, and that they have lives beyond their addictions.
Another way we can bridge gaps is by writing. With all the misinformation being spread on the internet and social media, it is important for those of us who are knowledgeable about addiction to actively share our knowledge with the public.
The PA Statewide Tobacco-Free Recovery Initiative is pleased to announce the June live webinar training schedule. Register by scanning the QR Codes below. You can also visit tobaccofreerecoverypa.cxom to register for additional 2025 training opportunities. All 60-minute presentations start at 12 p.m. There is no registration fee.
TUESDAY, JUNE 17
Pharmacotherapy: Managing Tobacco Withdrawal with Confidence
WEDNESDAY, JUNE 18
The Rationale: Addressing Tobacco Use in Behavioral Health Services
THURSDAY, JUNE 26
Tobacco Recovery: Learning to be Tobacco-Free!
FRIDAY, JUNE 27
Vaping: What We Know and What We Don’t Know
To this end, Dr. Santoro and I have written a book titled: Navigating the Methadone Maze - A Guide for Patients and Professionals, scheduled for release in June 2025. The book provides an overview of methadone treatment and includes several patient vignettes. It also addresses stigma and common concerns about methadone.
An excerpt from the foreword by Dr. David Mee-Lee reads:
“This book is an invaluable resource for both patients and professionals. It provides the knowledge, tools, and inspiration needed to navigate the complexities of methadone treatment and, ultimately, the path to recovery.”
It is our hope that this book will serve as a useful resource for patients and professionals alike, and that the patient stories included will help to humanize the population we serve.
By providing trainees with meaningful experiences and sharing our knowledge through teaching and writing, we can all contribute to bridging the gaps in healthcare.
Dr. Simoyan can be contacted at www.thedoctorwriter.com.
Where the Science of Treatment Meets the Heart of Care.
Caron Treatment Centers is an internationally recognized nonprofit dedicated to transforming lives through addiction and behavioral healthcare treatment, research, prevention, and addiction medicine education.
Caron’s neurorestorative approach combines proven treatment with innovative techniques that target the brain and redefines addiction and behavioral health treatment to give patients better outcomes and a stronger foundation for long-term recovery.
During its almost 70 years, Caron has helped thousands of individuals struggling with behavioral health issues, including substance use disorders, begin to manage these brain diseases, and find hope.
Caron provides a comprehensive continuum of care for teens through adults including medical stabilization and detoxification, residential, partial hospitalization, intensive outpatient, and outpatient programs, as well as recovery support, family, and alumni services. Caron is in network with most major insurance plans and provides financial assistance for those who qualify.
Supporting Individuals with Substance Use Disorder: A Clinical Experience
by Josette Graves, MS MD-MS Candidate, Class of 2026 Drexel College of Medicine at Tower Health
Introduction
My experience during the Bridging the Gaps program provided by Drexel University College of Medicine allowed me to deconstruct the stigma of addiction and regard it as a disease. Prior to interning at a local clinic in Wyomissing, PA, the words “methadone” and “suboxone” held little weight. I felt uncomfortable with my lack of knowledge regarding hepatitis, particularly hepatitis C, as a complication of substance use disorder. Now, these words and diagnoses hold new meaning. In addition, listening compassionately and utilizing motivational interviewing techniques during the visit may be just as important as clinical knowledge.
Experience
At the clinical site in Wyomissing, PA, I explored both the clinical aspects of substance use disorder and the social determinants of health. I was supervised by Mihaela Pendos, CRNP, PMHNP-BC, FNP-C. In addition to conducting interviews, I learned the following skills: how to perform a PPD skin test for tuberculosis, how to administer sublocade injections, and how to draw blood. I also learned to address oral health, mental health and cardiovascular health during patient interviews. Additionally, smoking cessation, weight management and safety counseling were incorporated into the discussions, while directing patients to the appropriate resources.
Since most patients came in to dose every day, I felt comfortable seeing them frequently and got to know them by name. I found myself getting worried when patients didn’t show up. The patients also expected to see me in the clinic daily. Just as we clinicians expect patients to show up for their visits, we must show up for our patients as well.
Learning Highlights
I was impressed by the incorporation of hepatitis C screening into the treatment plans. Hepatitis C is a virus that can be contracted from transfusions and sharing of needles.1 People struggling with substance use disorder often share needles and other equipment used to inject drugs, so they are at high risk of contracting
hepatitis C. Unfortunately, the infection often goes unnoticed for years and may lead to irreversible complications (cirrhosis, fibrosis, and cancer of the liver). While curative treatment is available, there is no vaccine, so screening and early detection are essential.
Special Clinical Moments
A middle-aged gentleman who was on suboxone maintenance presented for follow up. He expressed concern about multiple painful bumps on his body but was hesitant to get further testing done due to fear of receiving a cancer diagnosis. Upon further inquiry, I found out that he was close to the age at which his father had passed away due to metastatic cancer. I expressed sympathy and acknowledged that it must be difficult to navigate new health concerns, given his father’s experience. I waited a few moments, wondering if I should share a personal story. The fear of making the session about me instead of about the patient made me hesitant. Eventually, I decided that sharing may help the patient overcome his fear. The bandaged area underneath my right armpit covered a recent biopsy site. I explained that a mass had become painful and swollen, so I had it removed. Getting the biopsy brought me peace of mind and fortunately the biopsy result was negative. I also told him that the biopsy process was very quick, and the only painful part was the numbing medication. The patient expressed that he felt reassured. I mentioned the name of the clinic where I received care, and Mihaela also looked up another location in case the former did not take the patient’s insurance. Following the visit, I mentioned to Mihaela that I hoped I hadn’t crossed any boundaries by sharing my personal experience. She said that it was helpful for the patient’s care, adding that it is great to connect where possible.
I noticed myself being able to converse with patients with substance use disorder in a more relaxed way. One patient told me that she only comes to the clinic because of how wonderful Mihaela treats her, and she sees Mihaela as a large part of why she got better. It was amazing to hear about her
future plans (going to a concert on Sunday, spending time with her mom at the beach, and building a relationship with her fiancé). All those things were seemingly out of reach when she was living in Kensington, Philadelphia a few years ago. She is maintaining a full-time job, looks healthy, and expressed a positive outlook on life. She is taking a consistent dose of suboxone 4 mg daily and is following up with her other doctors. Even though I had just met this young woman, I felt so proud that she was able to make a lasting and positive change in her life. At this patient’s follow up appointment, I remembered her saying she was so excited to go to the Machine Gun Kelly (MGK) concert. I asked her about it, and she seemed surprised that I recalled our previous conversation. She proceeded to gush about the great time she had that evening. She appreciates MGK’s music because he talks about overcoming addiction, which resonates with her. I find it so important to remember some of the seemingly “little” things that patients tell us because they often provide a window into their values and identity.
Smoking Cessation and Oral Health
One of my goals at the clinic was to increase awareness of smoking cessation and oral health. Patients were interviewed using a standardized physical exam packet for their yearly physical in the clinic.
Substance use history is obtained, including the amount, frequency, number of years used, and the last time the substance was used. Such substances include heroin, other opiates, cocaine, benzodiazepines, amphetamines, tobacco, marijuana, alcohol, hallucinogens, and anything else the patient discloses. Patients who smoked were asked if the amount smoked had changed over the years. Motivational interviewing techniques were used and supportive resources, such as 1-800-Quit-Now (1-800-784-8669), were offered.
One day when the nurse practitioner was not in the clinic, I shadowed a physician assistant. I noticed that during his physical examination, he also asked the patients about their teeth. At the time,
one of the challenges in evaluating oral health was the use of masks. In the event patients could not take off their masks, we relied on selfreports. Follow-up questions were asked, such as, “When was the last time you went to the dentist?” “Do you have any missing teeth?” “Are your teeth sensitive?”
Building Trust
Health professionals who treat individuals with substance use disorder may have concerns regarding honesty; however, it is imperative that we assume the best in our patients. Additionally, I noticed in my interactions with patients that kindness and sympathy go a long way. Carefully listening, genuine interest in their lives, and celebrating successes allow patients to be vulnerable and build a foundation of trust. While most interactions were pleasant, a few patients were in a rush and did not want to be at the clinic. I understand the need to get in and out quickly, especially at a medical office. Some of my questions (e.g. “Are you interested in quitting smoking,” “Have you tried quitting in the past,” etc.) were met with a very abrupt “No,” making it difficult to engage them in a conversation. I am looking forward to growing my interview skills and incorporating more motivational interviewing techniques with my patients in the future.
Conclusion
The clinic provided a wonderful mosaic of experiences during Drexel’s Bridging the Gaps program. There is much to learn outside of the classroom, and celebrating wins with patients, no matter how seemingly small, is incredibly fulfilling.
Reference:
1. Di Marco L, La Mantia C, Di Marco V. Hepatitis C: Standard of Treatment and What to Do for Global Elimination. Viruses. 2022;14(3):505. Published 2022 Feb 28. doi:10.3390/v14030505
ADVANCING ADDICTION MEDICINE Highlights from the 2025 ASAM Conference
A Recap from the PSAM Editorial Committee
The 56th Annual Conference of the American Society of Addiction Medicine (ASAM), held April 24–27, 2025, in Aurora, Colorado, brought together over 2,500 clinicians, researchers, policymakers, and advocates in a pivotal moment for addiction medicine. The gathering, hosted at the Gaylord Rockies Resort & Convention Center, marked a reaffirmation of ASAM’s commitment to evidence-based treatment and a whole-person approach to care in the face of a rapidly evolving substance use landscape.
The conference’s more than 60 sessions and 100 poster presentations underscored a clear theme: addiction medicine must adapt to address not only the pharmacological aspects of treatment, but also the social, psychological, and systemic barriers that shape patient outcomes.
Several standout studies were recognized with awards for their contributions to the field. A study exploring intimate partner violence (IPV) among perinatal women with substance use disorders took home the Underserved Population Award. Its findings called for stronger integration of IPV screening and trauma-informed care into addiction treatment protocols—particularly for vulnerable populations navigating overlapping risks.
Equally compelling was research honored with the Student Award, which highlighted stark disparities in access to buprenorphine treatment. The data revealed that Black patients in rural and socioeconomically disadvantaged areas face significant geographic and systemic barriers, pointing to the need for deeper attention to equity in opioid use disorder (OUD) treatment strategies.
In Los Angeles, a study recognized with the Resident Award examined the addition of quetiapine—a sedative—to illicit heroin. The research raised questions about risk reduction in street-level drug formulation, noting that the mixture was not associated with increased overdose rates.
Meanwhile, emergency department-tomethadone clinic referrals proved effective, as noted in a study receiving the Representation in Research Award. Still, logistical challenges like transportation and housing were flagged as persistent hurdles to care.
Finally, the Fellow in Training Award recognized a sobering look at solitary drug use. The study linked isolation to heightened overdose risk, underlining the importance of reducing stigma and fostering supportive environments for safer substance use.
Altogether, the 2025 ASAM Conference underscored a vital shift: addiction medicine is moving beyond the clinic to confront the social realities shaping recovery.
continued on next page
PSAM was one of the first state chapters to have an APP Committee and ours is led by Arielle Bivas, CRNP, AGPCNP-BC. She participated in the ASAM Advocacy Conference, is active with ASAM Committees, and participates in PSAM Public Policy Committee as well.
Presenters from Jefferson Addiction Psychiatry Fellowship. Mentor and CBO Delaware Medicaid and Medical Assistance Dr. Sherry Nykiel with Jefferson’s Dr. Vybav Vyas and Dr. Stanley Nkemjika presenting “Maximizing AA Referrals: Understanding the History and Power of Self Help Meetings.” Dr. Vyas and Dr. Nkemjika also provide Addiction services in NET-Centers’ Integrated Care and Wellness Center (see Dr. Van Zant’s article on page 4).
James R. Latronica, DO, DFASAM, receives the DFASAM award from ASAM’s new President Dr. Stephen Taylor.
Front Row: Maia Szalavitz, Dr. Cara Poland
PSAM members were present for the ASAM Awards Ceremony and afterward shared a photo-op with award winners, including Dr. Cara Poland, whose award acceptance speech was described as “inspirational and an incredibly moving personal story. Dr. Poland has been an inspirational leader with years of educational, legislative, and ASAM organizational accomplishments.”
Pennsylvania Society of Addiction Medicine members gathered in the Colorado Ballroom after the Awards Ceremony for a quick photo-op.
Back Row: Left to Right: Dr. Margaret Jarvis, Dr. Aleksandra Zgierska, Dr. Bill Santoro, Dr. Yngveld Olsen (SAMHSA Liaison), Dr. Jim Latronica, Dr. Jan Widerman, Dr. Kristin Van Zant, Dr. Bhavna Bali
Comprehensive Case Management for Opioid Use Disorder (OUD)
Regardless of how an OUD patient enters into care, case management should connect them with the support they need.
Considerations for Treating the Whole Patient
Case management should be framed as working directly through community resources to screen for and address the patient’s medical, psychosocial, behavioral, and functional needs. In any type of model employed, all care team members should contribute to and endorse the patient’s treatment plan and effectively communicate with one another as the plan is implemented.1
Adverse childhood experiences (ACEs) are potentially traumatic events that occur before a child turns 18 and can interfere with a patient’s health, opportunities, and stability throughout their lifetime.2
Adverse Childhood Experiences2
Adverse Community Environments2
• Maternal depression
• Emotional and sexual abuse
• Domestic violence
• Discrimination
• Poor housing quality and affordability
• Physical and emotional neglect
• Homelessness
• Divorce
• Poverty
• Violence
• Community disruption
• Substance abuse
• Mental illness
• Incarceration
• Lack of opportunity, economic mobility, and social capital
ACEs can increase risk of disease, early death, and poor social outcomes. Experiencing a high number of ACEs is associated with many of the leading causes of death, like substance use.2
Principles of Effective Treatment3
› Evidence-based treatment
› Continuing care
› Assessment › Substance use monitoring
Components of Comprehensive Case Management3
Mental Health Services
Do the patient’s ACEs affect their current behavior?
What support is available to the patient, and which support networks resonate most with the patient?
Infectious Disease Services
Is the patient able to access drugs for treatment or prevention of infectious diseases?
Can this access be improved?
Is the patient aware of their risk for these diseases?
Educational Services
Is the patient interested in continuing their education, and will this improve their recovery?
What resources does the program have to assist in the educational growth of the patient?
Vocational Services
What vocational assistance resources does the patient have access to?
Are other forms of work assistance accessible to the patient?
References:
› Clinical and case management › Recovery support programs
Legal Services
What laws and regulations guide treatment and support guidelines where the patient lives?
Is the patient aware of any legal support the program can provide?
Family Services
Does the patient have family members or friends who are willing to support them?
How does family history affect the patient currently?
Does the patient need child care while undergoing therapy?
Medical Services
Does the patient know their treatment options?
Does the patient have health insurance or know how to get it? Are other medical programs and payment assistance available?
1. Substance Abuse and Mental Health Service Administration (SAMHSA). Comprehensive Case Management for Substance Use Disorder Treatment. 2021. PEP20-02-02-013. Accessed February 20, 2025. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-02-02-013.pdf
2. National Conference of State Legislatures (NCSL). Adverse Childhood Experiences. NCSL. Updated August 23, 2022. Accessed February 20, 2025. https://www.ncsl.org/health/adverse-childhood-experiences
3. Vantage Point. The Components of Comprehensive Drug Addiction Treatment. VantagePointRecovery.com. Accessed February 20, 2025. https://vantagepointrecovery.com/the-components-of-comprehensive-drug-addiction-treatment/ © 2025 Indivior UK Limited | INDIVIOR® is a registered trademark of Indivior UK Limited or its affiliate companies. | All rights reserved. NP-NBD-US-01375 Apr 2025
The Neurobiology of Addiction
by William Santoro, MD, FASAM, DABAM
Addiction, now often referred to as “substance use disorder,” is a primary, treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. The brain circuitry addiction effects are those of reward, motivation, learning, judgment, and memory. The dysfunction of addiction leads to characteristic biological, psychological, sociological and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use. Addiction can be defined as a chronically relapsing disorder, characterized by compulsion to use a substance, loss of control in limiting the use of a substance, and emergence of a negative emotional state, withdrawal, when access to the substance is prevented. DSM-5 combined two separate disorders, substance abuse and substance dependence, into substance use disorder (Addiction) with a range of mild, moderate, to severe.
Addiction is characterized by the inability to consistently abstain from use, impairment in behavioral control, craving, diminished recognition of problems with behaviors, and diminished recognition of problems with interpersonal relationships. To separate addiction from other neurological disorders, four factors must be present. These four factors, compulsion, craving, consequences and control, are simply referred to as the 4 Cs. Although no other chronic disease has the 4 Cs, addiction does have a lot in common with other chronic diseases. Like other chronic diseases, addiction involves cycles of relapse and remission. Like any other chronic disease, including diabetes, cancer, and heart disease, addiction is caused by a combination of behavioral, psychological, environmental, and biological factors. While genetics play a key role, it is estimated that they are responsible for only about half of a person’s risk of developing a substance use disorder. Without treatment or engagement in recovery activities, addiction is very often progressive and can result in disability or premature death. Addiction is considered a disease by most medical associations, including the American Medical Association and the American Society of Addiction Medicine.
is believed to be the neurotransmitter (hormone) responsible for addiction, due to its role in producing euphoria. The difference between normal activity, other neurological disorders, and addiction is that substance use disorder causes the brain to release high levels of dopamine that cause extreme feelings of pleasure. Continued substance use causes the brain to release more dopamine, which ultimately results in changes in the brain’s reward and motivation systems as well as memory. Dopamine rewards the individual and as the individual commits the experience to memory, it sets the individual up to repeat the behaviors that produce those feelings. This is no different than how healthy habits are formed. In this sense, humans are no different than Pavolvian dogs or Skinner pigeons.
The difference between normal activity, other neurological disorders, and addiction is that substance use disorder causes the brain to release high levels of dopamine that cause extreme feelings of pleasure.
The normal developmental changes might result in higher risk for drug use at some stages of a person’s life than other stages. Experimentation, and a path toward addiction, often begins in adolescence, a time when the brain undergoes important developmental changes. Beginning in preadolescence and continuing into the mid20s, cortical grey matter volume decreases, part of the normal pruning process, and white matter volume increases, resulting in increasing connectivity. Drug exposure during adolescence is associated with more chronic and intensive use and greater risk of a substance use disorder than when the use is started at a later age. Normal adolescent-specific behaviors, such as risk-taking, novelty-seeking, and sensitivity to peer pressure, increase the likelihood to experiment with legal and illegal drugs. These activities may be due to incomplete development of brain regions that are involved in executive control and motivation. Heavy alcohol use during adolescence is associated with a range of neurobehavioral problems, including impairments in visuospatial processing, attention, and memory. Adolescents who drink heavily have had faster declines in the grey matter and smaller increases in white matter volumes than adolescents who were not heavy drinkers.
People feel pleasure when basic needs, such as hunger and thirst, are satisfied. In most cases, these feelings of satisfaction are caused by the release of certain chemicals in the brain. Dopamine
Certain environmental factors such as low socioeconomic status, weak social support systems, parental drug use, parental depression, general poor parenting, and drug availability due to poor neighborhoods have been associated with increased risk of drug use. Stress is also a common feature that increases the risk for drug abuse. The mechanisms responsible for increased risk of drug use due to stress are not yet well understood but are likely due to the stress-responsive neuropeptide, corticotropin releasing factor (CRF) through its effects in the
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amygdala and hypothalamic-pituitary-adrenal axis, part of the pleasure center of the brain.
As a person continues to use substances, the brain tries to get back to a balanced state by reacting less to those rewarding chemicals. This is called adaptation. As a result, a person may need to use more of the substance just to feel the same way they felt with lower amounts.
Normal, healthy dopamine production depends on a wide variety of factors, but many medical professionals believe that the brain’s dopamine production will return to pre-substance misuse levels over a period of about 90 days.
This is called tolerance. Neuroadaptation refers to the processes by which initial drug effects are either enhanced (sensitization) or attenuated (counteradaptation) by repeated drug exposure. Drug-related responses (reinforcement) are modulated by the neuroadaptive changes that occur with repeated drug exposure. Addiction alters the brain’s mesolimbic dopamine pathway, also known as the reward circuit, which begins in the ventral tegmental area (VTA) above the brain stem. Dopaminergic neurons arise in the VTA, and their axons extend to the nucleus accumbens. Disruptions in these three areas of the brain, the prefrontal cortex, the VTA, and the nucleus accumbens, are particularly important in the onset, development, and maintenance of substance use disorders.
Adaptation and tolerance result in a person having strong desires or urges to continue to use a substance to revisit the sensation the release of dopamine will give, even if there are harmful or dangerous consequences. Furthermore, with many substances a person may continue to use simply to avoid feeling sick (withdrawal). As the pattern of use causes more dopamine to be released and used, the result is a lower baseline of dopamine. When the use stops, the deficit of dopamine causes the reverse sensation that the substance use caused. This is called withdrawal. Once this damage has occurred, the brain can heal, but it takes time. Normal, healthy dopamine production depends on a wide variety of factors, but many medical professionals believe that the brain’s dopamine production will return to presubstance misuse levels over a period of about 90 days. Because of the time needed, those with a substance use disorder are at risk of returning to use due to triggers. A common term to describe triggers used by those in recovery is “people, places and things.” A trigger can be meeting up with a person who the patient has used with in the past, going to a restaurant or bar the patient used to frequent, or simply seeing a glycine envelope from a package. Many people can be triggered to use by seeing substance use in a movie or hearing a song associated with their previous drug use.
The goal for someone with an SUD may be to stop them from using substances entirely. However, it is important to take whatever steps needed to reduce the risks associated with substance use. In the case of opioid use disorder, these strategies include the use of fentanyl test strips, needle exchange programs, expanding the access to naloxone, and even the creation of safe injection sites along with medication such as naltrexone, buprenorphine, or methadone.
Some people think addiction is not a disease because it is caused by the individual’s choice to use substances. While it is true that a person’s first use, and even into a person’s early use, there may be a choice; however, once the brain has been changed by addiction, the person loses control of their behavior. Choice does not determine whether something is a disease. Heart disease, diabetes and certain skin cancers involve personal choices like diet, exercise, and sun exposure. A disease is what happens as a result of those choices. Others argue that addiction is not a disease because some people with addiction get better without treatment. Most people who engage in substance use do not develop addiction, and many young people tend to reduce their use once they take on more adult responsibilities. People with a mild SUD may recover with little or no treatment. People with the most serious form of SUD usually need intensive treatment followed by lifelong management of the disease. However, some people experiencing addiction stop drinking or using other substances without treatment. Others achieve recovery by attending self-help meetings without receiving much, if any, professional treatment. Still, about 25-50% of people with a substance use problem develop a severe, chronic disorder. A chronic disease is a long-lasting condition that can be controlled but not cured.
In all cases, professional treatment and recovery supports should be made available to anybody who develops a substance use disorder. Addiction is a brain disease resulting in long-lasting changes in brain structure and function, specifically in the reward system. Advances in neurobiology have provided crucial insights into how addiction works, leading to the development of effective treatments. A combination of pharmacological and behavioral approaches offers the best chance for individuals to overcome addiction and lead fulfilling lives in remission or recovery. Remission is when a person decreases their use to a level that they no longer reach the criteria for substance use disorder. Recovery includes an improvement in the social determinants such as employment and a reconnection to family. Recovery occurs after remission. Bottomline… addiction is a treatable disease.
This article was originally published in the Spring 2025 issue of Berks County Medical Record.
Can Emergency Departments Provide Effective Harm Reduction Resources in Rural Settings?
by Julia Kooser
Despite the well-established, life-saving benefits of providing naloxone within emergency departments, disparities exist in naloxone availability between rural and urban hospitals—largely due to access and funding constraints.1,2 Hospitals in rural areas are also less likely to provide comprehensive care for opioid use disorder, such as naloxone distribution, medications for opioid use disorder (MOUD), and addiction consult services.1,2 In a recent study using data from hospitals nationwide, rural hospitals had significantly lower rates of addiction consult services in both emergency and inpatient settings compared with their urban counterparts.² These discrepancies, among other factors limiting access to addiction care in rural communities, have cost lives. In a world where harm reduction supplies are abundant but imperfectly distributed, as medical students and aspiring addiction medicine physicians, we are eager to make evidence-based harm reduction supplies widely available in the rural community where we train.
or provide training, with some pharmacists endorsing beliefs that supplying naloxone enabled risky behavior.⁴ Lack of supplies and stigma were associated with fewer naloxone kits dispensed.⁴
Addressing disparities in opioid use disorder treatment is imperative. Implementing naloxone distribution and other harm reduction measures within emergency departments may serve as a simple, effective strategy.⁵
Illegally obtained opioids increasingly contain fentanyl, a synthetic opioid 50 times more potent than heroin and 100 times stronger than morphine.6,7 Fentanyl’s potency largely accounts for the increase in overdose deaths.⁸ Many deaths occurred in the context of mixed drug toxicity
sense of commitment to their communities and concern about delayed emergency response times. More than half had previously used naloxone, often influenced by prior education.¹³ These findings show that sustained harm reduction education can empower safer behaviors.
Fentanyl test strips have also been associated with safer drugusing behaviors. Of 125 individuals who injected drugs, 43% reported engaging in safer behaviors, such as using smaller doses or not using substances alone, after using test strips.¹
Given the many barriers faced by individuals with OUD in rural communities, emergency department-based naloxone and fentanyl test strip (harm
and overdose deaths that occured statewide during the early stages of the the COVID-19 pandemic.
Despite the rise in overdose rates, barriers to treatment for opioid use continue to exist in rural communities. Restrictions placed on providers’ ability to manage opioid use disorder, reduced stocking of naloxone in pharmacies, and individuals’ own pre-existing biases related to naloxone use contribute to this issue. For example, a study assessing naloxone dispensing patterns across pharmacies in Alabama found that independent pharmacies, most often located in rural areas, were less likely to stock naloxone and to provide training on its use.4 Pharmacists also endorsed beliefs that perpetuated stigma and bias, such that supplying naloxone enabled future risky behavior.4 Lack of supplies and pre-conceived beliefs were ultimately associated with fewer naloxone kits dispensed.4
As medical students rotating at a community hospital in Bradford County, we are excited about the opportunity to provide free naloxone and fentanyl test strips to individuals at risk of overdose.
With the significant rise in opioid overdoses and overdose deaths during the COVID-19 pandemic, urban-rural disparities in access to addiction treatment and harm reduction services were magnified. Bradford County, located in NorthCentral Pennsylvania, experienced a statistically significant increase in opioid-related overdoses from 2019–2020 (p<0.013) – reflecting a broader trend of increasing drug overdose and overdose death rates that occured statewide during the early pandemic.
While 2023 brought a monumental 9.3% decline in overdose deaths statewide, barriers to treatment persist in rural communities. The shortage of addiction providers and reduced naloxone stocking in pharmacies are significant contributors, and stigma and biases remain pervasive. An Alabama study found independent rural pharmacies were less likely to stock naloxone
or transdermal administration for breakthrough pain.⁹ Despite high fatal overdose risk, many individuals hesitate to test their substances for fentanyl due to stigma and fear of legal or social consequences.¹⁰
A retrospective cohort study of the VA Corporate Data Warehouse found that rural patients were less likely to receive methadone or naltrexone for opioid use disorder, though more likely to receive buprenorphine.¹¹ Additionally, rural patients had lower treatment initiation and engagement rates, and higher out-of-network treatment rates, compared to urban patients.¹² These trends reinforce the need for new harm reduction resources, with Emergency Departments as a highly effective distribution site.
In semi-structured interviews in New Brunswick and Newark, New Jersey, individuals who used drugs and participated in overdose education and naloxone distribution (OEND) programs showed a strong willingness to accept naloxone after educational interventions.¹³ Many cited a
reduction supplies) distribution may help to address critical barriers to access. As medical students rotating at a community hospital in Bradford County, we are excited about the opportunity to provide free naloxone and fentanyl test strips to individuals at risk of overdose. We will also invite patients to anonymously complete surveys about barriers to care in rural settings. By gathering these perspectives, we hope to better understand the needs of Bradford County’s population and work towards patient-centered interventions that address barriers to care.
With the statistically significant increase in opioid-related overdoses that occurred during the COVID-19 pandemic in many rural communities, the discrepancies in treatment between geographic locations are even more concerning. Located in North-Central Pennsylvania, Bradford County experienced a statistically significant increase in opioid related overdoses from 2019-2020, (p<0.013) – a trend that reflects increases in drug overdoses
Addressing the disparities in treatment availability for opioid use disorder is imperative for improving patient outcomes. Implementing naloxone distribution programs and providing other harm reduction measures within emergency departments may serve as a simple and effective tool for mitigating the effects of opioid use disorder in rural communities.5
Illegally obtained opioids are increasingly likely to contain fentanyl, a synthetic opioid estimated to be 50 times more potent than heroin and 100 times stronger than morphine. 6,7 The extreme potency of fentanyl largely accounts for the recent increase in overdoserelated deaths.8 Additionally, many fentanyl related deaths occurred within the setting of mixed drug toxicity (such as benzodiazepines and methamphetamines). Also, they occurred with transdermal drug administration in individuals trying to self-manage breakthrough pain).9 Despite the high risk of fatal overdose with fentanyl, many individuals who use drugs are hesitant to test for the presence of fentanyl in their substances. This reluctance is largely due to
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misconceptions and stigma surrounding drug use.10 Social and legal consequences of drug use may dissuade people from testing their substances for the presence of fentanyl, even if such testing would promote safer drug use and reduce the risk of overdose-related fatality.
As ascertained by a retrospective cohort study of the VA Corporate Data Warehouse, patients within rural healthcare settings were less likely to receive medications, specifically naltrexone and methadone, for opioid use disorder than their counterparts in urban locations 11. Interestingly, while patients were less likely to receive methadone and naltrexone in rural settings, they were more likely to receive buprenorphine.11 Additionally, patients in rural settings had lower treatment initiation rates, lower treatment engagement rates, and higher out-of-network treatment rates for substance use disorders compared to their counterparts in urban areas.12 This lack of medication assistance and treatment availability in rural areas reinforces the need for new harm-reduction resources, with the Emergency Department serving as a highly effective vehicle for distributing these resources.
When taking part in semi-structured interviews in New Brunswick and Newark, New Jersey, individuals who used drugs and participated in overdose education and naloxone distribution (OEND) programs demonstrated a strong willingness to accept naloxone following educational interventions. 13 When asked about the motivation to accept naloxone, many individuals cited a strong sense of commitment and responsibility to their communities, as well as concern over delayed and inconsistent emergency response times.13 Notably, more than half of the participants stated that they had previously used naloxone as an opioid overdose intervention.13 Individuals stated that prior education and information about naloxone directly influenced their decision to previously administer it.13 These findings show that sustained harm reduction education can empower people to engage in safer behaviors with opioid use.
The use of fentanyl test strips has been associated with safer drug-using behaviors and an increase in perceived safety when using drugs. Of 125 individuals who injected drugs, 43% of participants reported engaging in safer behaviors, such as taking smaller doses and not using substances alone, after using fentanyl test strips.14 These findings demonstrate the role of fentanyl testing strips in promoting safer drug use behavior and reducing the rate of fatalities from fentanyl use.
The barriers to addition treatment in rural communities are complex–with structural factors and social determinants of health at
play. While there is single quick fix that will address all these complexities, emergency department-based harm reduction supplies distribution programs may help to address critical access disparities affecting rural communities. We are excited about the opportunity to provide free naloxone and fentanyl test strips to individuals at risk of
Individuals stated that prior education and information about naloxone directly influenced their decision to previously administer it.13
overdose at our training hospital in Bradford County. As eliciting patient perspectives is an imperative part of effective harm reduction, we will also invite patients to complete anonymous surverys that assess barriers and treatment preferences. We hope that surveys will allow us to develop a better understanding of the needs of the population we treat such that we can develop future interventions that align with their preferences. We acknowledge that addressing the breadth of addiction treatment disparities in Bradford County will require much work and will involve implementing social determinants of healthrelated interventions as well as pervasive stigma. However, we begin this journey by implementing a patient-center, Emergency Department-based harm reduction supplies distribution program which, we hope, can pave the way toward improved access.
References:
1. Faul M, Dailey MW, Sugerman DE, Sasser SM, Levy B, Paulozzi LJ. Disparity in naloxone administration by emergency medical service providers and the burden of drug overdose in US rural communities. Am J Public Health. Jul 2015;105 Suppl 3(Suppl 3):e26-32. doi:10.2105/AJPH.2014.302520
2. Franz B, Cronin CE, Lindenfeld Z, et al. Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. J Subst Use Addict Treat. May 2024;160:209280. doi:10.1016/j.josat.2023.209280
3. King B, Holmes LM, Rishworth A, Patel R. Geographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemic. Health Place. Jan 2023;79:102938. doi:10.1016/j.healthplace.2022.102938
4. Sisson ML, McMahan KB, Chichester KR, Galbraith JW, Cropsey KL. Attitudes and availability: A comparison of naloxone dispensing across chain and independent pharmacies in rural and urban areas in Alabama. Int J Drug Policy. Dec 2019;74:229-235. doi:10.1016/j.drugpo.2019.09.021
5. Sindhwani MK, Friedman A, O’Donnell M, Stader D, Weiner SG. Naloxone distribution programs in the emergency department: A scoping review of the literature. J Am Coll Emerg Physicians Open. Jun 2024;5(3):e13180. doi:10.1002/emp2.13180
6. Rothberg RL, Stith K. Fentanyl: A Whole New World? J Law Med Ethics. Jun 2018;46(2):314324. doi:10.1177/1073110518782937
7. Comer SD, Cahill CM. Fentanyl: Receptor pharmacology, abuse potential, and implications for treatment. Neurosci Biobehav Rev. Nov 2019;106:49-57. doi:10.1016/j.neubiorev.2018.12.005
8. Han Y, Yan W, Zheng Y, Khan MZ, Yuan K, Lu L. The rising crisis of illicit fentanyl use, overdose, and potential therapeutic strategies. Transl Psychiatry. Nov 11 2019;9(1):282. doi:10.1038/s41398-019-0625-0
9. Cheema, E., McGuinness, K., Hadi, M. A., Paudyal, V., Elnaem, M. H., Alhifany, A. A., Elrggal, M. E., & Al Hamid, A. (2020). Causes, Nature and Toxicology of Fentanyl-Associated Deaths: A Systematic Review of Deaths Reported in Peer-Reviewed Literature. J Pain Res, 13, 3281-3294. https://doi.org/10.2147/JPR.S280462
10. Davis S, Wallace B, Van Roode T, Hore D. Substance Use Stigma and Community Drug Checking: A Qualitative Study Examining Barriers and Possible Responses. Int J Environ Res Public Health. Nov 30 2022;19(23)doi:10.3390/ijerph192315978
11. Reynolds, O. C., Carlson, K. F., Gordon, A. J., Handley, R. L., Morasco, B. J., Korthuis, T. P., Lovejoy, T. I., & Wyse, J. J. (2025). Receipt of medications for opioid use disorder among rural and urban veterans health administration patients. Drug Alcohol Depend Rep, 14, 100311. https://doi.org/10.1016/j.dadr.2024.100311
12. Raver, E., Retchin, S. M., Li, Y., Carlo, A. D., & Xu, W. Y. (2024). Rural-urban differences in out-of-network treatment initiation and engagement rates for substance use disorders. Health Serv Res, 59(5), e14299. https://doi.org/10.1111/1475-6773.14299
13. Enich M, Flumo R, Campos S, et al. Overdose education and naloxone distribution program design informed by people who use drugs and naloxone distributors. Prev Med Rep. Oct 2023;35:102374. doi:10.1016/j.pmedr.2023.102374
14. Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy. 2019/01/01/ 2019;63:122-128. doi:https://doi.org/10.1016/j.drugpo.2018.08.007
NET ADDICTION RECOVERY PROGRAMS
Embracing the possibility of recovery for life
NET’s compassionate care and commitment to community engagement helps individuals and families heal, recover, and rebuild their lives. We are nationally recognized as a leader in recovery transformation.
NET (NorthEast Treatment Centers)
7520 State Road, Philadelphia PA, 19136
NET Centers (NET) provides individualized treatment, specialized services, and ongoing support to sustain recovery that focuses on trauma informed care and evidence based programing. The recovery continuum in both traditional and medication assisted modalities includes:
• Medications for opioid use disorder (Methadone, Buprenorphine, and Naltrexone/Vivitrol)
• Outpatient and Intensive Outpatient (IOP)
• Prison-based treatment (opioid use disorders only)
• Residential treatment
We also offer a unique after-care resource called the NET Works Recovery Support Center, completely managed by people in recovery. We support innovative programming such as our CCBHC and the Integrated Care and Wellness Center, providing an integration of physical and mental health services along with substance use services in one location.
In addition to our recovery programs, NET is committed to offering support and help to individuals and families at times of great stress in their lives, including child welfare, juvenile justice, and mental health services.
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Demystifying the Molecular Mechanism of GLP-1 Agonists in Substance use Disorder:
Focus on Dopamine and Serotonin Systems
Authors: Parul Chhatpar, DO, UMass Chan Medical School, Worcester, MA
Mohit Chhatpar, DO, Indiana Rzegional Medical Center, Indiana, PA
Gregory Doke, MD, Indiana Regional Medical Center, Indiana, PA
Kayla Bryant, DO, Indiana Regional Medical Center, Indiana, PA
Introduction
Overview of substance use disorder (SUD)
Substance Use Disorder (SUD) is a major global health challenge, affecting over 35 million individuals worldwide and contributing to significant morbidity and mortality (World Health Organization, 2023).
Responsible for approximately 500,000 preventable deaths annually and millions of disabilityadjusted life years lost, SUD also imposes an immense socioeconomic burden on healthcare systems, families, and communities globally.
SUD is characterized by compulsive drug-seeking behavior, tolerance development, and withdrawal symptoms. It causes persistent structural and functional changes in the brain, particularly in regions such as the ventral tegmental area (VTA), nucleus accumbens (NAc), and prefrontal cortex, which are critical for reward processing, motivation, and decision-making (Bayassi-Jakowicka et al., 2021). Substances such as opioids, alcohol, methamphetamine, nicotine, and cocaine disrupt the brain’s natural reward pathways by enhancing dopamine release, inducing euphoria, and reinforcing substance use behaviors (Polites et al., 2024). Over time, chronic substance use exacerbates dysregulation of dopaminergic and serotonergic systems, making recovery challenging (Nunes et al., 2022).
Current treatments for substance use disorder and challenges
Pharmacological treatments for SUD, such as buprenorphine, methadone, and naltrexone, primarily target cravings and withdrawal symptoms. However, these treatments are associated with several limitations, including side effects like nausea, headache, and insomnia, as well as varying efficacy across different substances (Montoya & Volkow, 2024). For example, while methadone and buprenorphine are effective for opioid use disorders, they are less useful for stimulant use disorders such as methamphetamine addiction. Furthermore, these
therapies fail to address the systemic neurobiological and metabolic changes associated with chronic substance use, particularly those linked to glucose homeostasis.
Emerging evidence suggests that substance use, especially alcohol, opioids, and stimulants, disrupts glucose metabolism, leading to energy deficits in brain regions such as the prefrontal cortex and nucleus accumbens, which are critical for decisionmaking, motivation, and reward processing (Volkow et al., 2020). These disruptions contribute to cognitive impairments, heightened cravings, and relapse risk. Current SUD therapies do not effectively address these metabolic imbalances, leaving a critical gap in treatment approaches. GLP-1 agonists, widely recognized for their role in glucose
several critical gaps persist. First, there is a lack of effective treatments targeting the dysregulated dopamine and serotonin pathways that drive compulsive substance use and relapse. Second, while preclinical research has highlighted the potential of GLP-1 agonists to modulate rewardrelated brain circuits and reduce cravings, their application in SUD remains underexplored. The clinical evidence for GLP-1 agonists in SUD is sparse, and the mechanisms through which these agents influence addiction-related neurochemical systems are not fully understood.
This paper addresses these gaps by providing a comprehensive review of the mechanisms through which GLP-1 agonists modulate dopaminergic and serotonergic
Emerging evidence suggests that substance use, especially alcohol, opioids, and stimulants, disrupts glucose metabolism, leading to energy deficits in brain regions such as the prefrontal cortex and nucleus accumbens, which are critical for decision-making, motivation, and reward processing (Volkow et al., 2020).
homeostasis, may offer a dual therapeutic benefit by restoring metabolic balance and targeting addiction-related neurobiological pathways.
Behavioral therapies such as cognitive-behavioral therapy (CBT) have been utilized alongside pharmacological treatments. However, their long-term efficacy is uncertain, particularly in the absence of therapies that address both the metabolic and neurochemical mechanisms underlying addiction. This underscores the urgent need for novel therapeutic strategies that integrate metabolic and neurobiological targets.
Research Gaps Addressed in This Paper
Although significant advances have been made in understanding the neurobiology of addiction,
systems in the context of SUD. It also evaluates findings from preclinical studies and emerging clinical trials, exploring the potential of GLP-1 agonists as a novel therapeutic approach for addiction. By doing so, this paper seeks to advance the understanding of how these agents could bridge the current gap between neurobiological insights and effective clinical interventions.
GLP-1 and its role in metabolic disorders
GLP-1 agonists, widely used in the treatment of type 2 diabetes and obesity, enhance glucose homeostasis by stimulating insulin secretion from pancreatic β-cells in a glucose-dependent manner and suppressing glucagon release from α-cells (Ja’arah et al., 2021). These actions help regulate blood glucose levels and prevent hypoglycemia, a common risk associated with other
diabetes treatments. Additionally, GLP-1 agonists slow gastric emptying and promote satiety, aiding in weight loss (Peart et al., 2024).
Role of GLP-1 agonists in SUD
Glucagon-like peptide-1 (GLP-1) is an incretin hormone secreted in response to food intake that regulates blood glucose by stimulating insulin release and suppressing glucagon secretion. Additionally, GLP-1 slows gastric emptying and promotes satiety, making it an essential target for managing metabolic disorders such as type 2 diabetes and obesity (Holst, 2024).
GLP-1 receptors, which are G protein-coupled receptors (GPCRs), are expressed in both peripheral tissues and the central nervous system (CNS). Within the CNS, these receptors are distributed in regions such as the hypothalamus, brainstem, VTA, and NAc—areas implicated in reward processing, motivation, and addiction (Arillotta et al., 2024). Activation of GLP-1 receptors modulates neurotransmitter release, particularly dopamine and serotonin, which are dysregulated in SUD (Badulescu et al., 2024). Preclinical research suggests that GLP-1 receptor activation can reduce cravings for substances like alcohol, cocaine, and methamphetamine by modulating reward pathways (Jerlhag, 2023; Kalusen et al., 2022). These findings position GLP-1 agonists as promising candidates for addiction treatment.
In the context of SUD, these glucose-regulating properties may directly influence addiction-related behaviors. Chronic substance use has been shown to impair glucose metabolism in the brain, leading to reduced availability of energy in key regions such as the prefrontal cortex and nucleus accumbens. This energy deficit exacerbates impulsivity, poor decision-making, and the reinforcement of drug-seeking behaviors. By improving systemic and central glucose homeostasis, GLP-1 agonists may help restore energy availability in these regions, supporting cognitive function and reducing the neurobiological drive for substance use.
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Mechanism of action of GLP-1 agonists
GLP-1 agonists have been used for a long time for their efficacy in maintaining glucose homeostasis, which makes them effective for treating type 2 diabetes. These agonists allow insulin release from β-cells of pancreas when blood glucose levels are elevated and thus improve glucose dependent insulin secretion. This in turn minimizes the risk of hypoglycemia, which is a common side effect of other diabetes medicines (Ja’arah et al., 2021). GLP-1 agonists are also found to suppress glucagon secretion from α-cells of pancreatic, which lower the glucose production from liver and thereby reduces blood glucose levels (Peart et al., 2024).
Long-term use of GLP-1 agonists has been useful for managing progressive diabetes by enhancing β-cell mass and function (Zhao et al., 2021). This could be correlated with physiological impact of GLP-1 agonist on gastrointestinal processes, particularly in gastric emptying. This extends the feeling of fullness and reduces food craving behavior which is essential for weight loss (Kalusen et al., 2022). Furthermore, GLP-1 agonists are known to act on the brainstem and hypothalamus to decrease appetite and caloric intake which is achieved via regulation of energy balance by modulating of neuropeptide Y (NPY) and proopiomelanocortin (POMC) neurons in the hypothalamus (Chen et al., 2021).
In this connection, as mentioned earlier, GLP-1 receptors are expressed in the VTA and NAc; their activation in these areas can reduce substance addictive behavior by modulating the reward system via dopamine release (Dixon et al., 2020). Activation of GLP-1 receptors in these areas also helps in reducing cravings for substances by modulating the reward system and dopamine release. This effect on cravings is important in reducing compulsive drug seeking behavior (Jerlhag, 2023). Investigation by Egecioglu et al. (2013) confirmed exendin-4, a GLP-1 agonist, reduces nicotine intake in rats via reducing cravings which is likely due to their effect on reward circuits in the brain that overlap with other addictive substances (Egecioglu et al., 2013).
In addition to regulating dopamine signaling, GLP-1 agonists also impact serotonin signaling. Serotonin release and reuptake have been found to be influenced by the GLP-1 receptors located on serotonergic neurons (Smith et al., 2019). Meanwhile serotonin system modulation by GLP-1 agonists influence emotional balance and mood regulation thus they could also help to alleviate the emotional dysregulation usually seen in persons with SUD.
How GLP-1 agonists modulate the dopamine and serotonin systems in SUD: Preclinical and clinical studies
Role of dopamine and serotonin in addiction
Dopamine plays a major role in addiction by mediating reward and reinforcement pathways in the brain. Substances such as opioids, methamphetamine, and cocaine were found to significantly increase dopamine levels of the NAc, reinforcing drug-taking behavior and triggering euphoria. Substance use for a long time disturbs the normal dopamine signaling, and decrease sensitivity of the brain to natural rewards and driving compulsive drug-seeking behavior. In SUD this dysregulation forms a major hallmark which makes dopamine signaling a major target for therapeutics (Volkow et al., 2019; Wise & Robble, 2020). Similarly, serotonin is known to play a vital role in impulse control, mood regulation, and anxiety that are the factors closely linked to addiction. Serotonergic system has been found to be highly dysregulated in individuals with SUD (Blum et al., 2017; Erickson, 2018). The combinatorial effect of SUD on the two major neurotransmitter pathways adds further complexity to the addiction neurobiology (Popescu et al., 2021).
Dopamine and serotonin release and uptake affected by GLP-1 agonists
There are several findings indicating dopamine system modulation capability of GLP-1 agonists under drug addiction. GLP-1 receptor agonists regulate dopamine
release and uptake in craving and reward-related brain regions, like NAc. Preclinical research on GLP-1 agonists, demonstrates that they reduce substance induced dopamine release, thus lessening the rewarding effects of substances like alcohol, cocaine and methamphetamine. For example, liraglutide, a GLP-1 agonist, was found to reduce dopamine release in the NAc and decrease alcohol consumption in rodents (Vallöf et al., 2016). The study highlighted that both the rewarding effects of alcohol and the cravings were reduced by liraglutide.
Similarly, another GLP-1 agonist, Exendin-4, has been shown to reduce conditioned place preference (CPP) in mice under cocaine addiction (Graham et al., 2013). In the same way, both shortand long-term administration of Exendin-4 was found to decrease dopamine release and cocaine selfadministration in mice (Sørensen et al., 2015). As far as dopamine reuptake ability of GLP-1 agonist under SUD is considered there is only one study by Fortin and Rotiman, which revealed that Exendin-4 could suppresse cocaine induced dopamine release in the NAc core, without affecting dopamine reuptake in male Sprague-Dawley rats (Fortin and Rotiman, 2017).
On the other hand, GLP-1 agonists may decrease serotonin release under SUD condition while via enhancing serotonin reuptake in the brain. Chronic administration of liraglutide in rodents decreased ethanol intake by modulating serotonin and dopamine levels in the amygdala and striatum (Vallöf et al., 2020).
Similarly, semaglutide revealed its effectiveness in reducing alcohol consumption in mice through modulating GABA neurotransmission, providing further support for its potential use in treating SUD (Chuong et al., 2023). These findings support the potential of GLP-1 agonists as therapeutic agents for SUD.
While literature study showed several promising preclinical data, most of the clinical studies have focused on the palatable food intake and obesity, while studies are still
limited on using GLP-1 agonists in different SUDs.
Challenges and future perspectives
Despite promising preclinical data, several challenges must be addressed to translate GLP-1 agonists into clinical practice for Substance Use Disorder (SUD). A more comprehensive understanding of the neural circuits involved in GLP-1 modulation of dopamine and serotonin systems is required to elucidate their mechanisms in addiction treatment fully. Furthermore, clinical evidence remains limited, as most trials investigating GLP-1 agonists have focused on metabolic disorders rather than SUD. This leaves a significant gap in understanding their therapeutic effectiveness for addiction. Another key challenge is the potential for tolerance development with prolonged use, which could diminish the therapeutic benefits of GLP-1 agonists over time.
Future research should focus on clinical trials for validating the efficacy of GLP-1 agonists in various SUDs, including opioid, methamphetamine, cocaine, and alcohol dependence. There is also the possibility of developing personalized medicines where individual GLP-1 receptor polymorphisms could be used to treat people with SUD more efficiently. Further, combination therapies including GLP-1 agonists and existing therapies could be explored for their efficacy. Beyond these scientific challenges, there are translational hurdles to consider. Regulatory approval for using GLP-1 agonists in SUD treatment requires robust clinical trial data to establish efficacy and safety. Additionally, cost-effectiveness and accessibility are major considerations. GLP-1 agonists, originally developed for diabetes and obesity, are often expensive and may be inaccessible to underserved populations affected by SUD. Addressing these barriers is essential to ensure equitable access to treatment if these drugs are approved for addiction management.
Conclusion
GLP-1 receptor agonists signify a novel approach to address the neurochemical imbalances in SUDs. These agents target dopamine and serotonin systems which are implicated in addiction. Preclinical evidence demonstrates their ability to reduce drug-induced dopamine release and cravings while improving emotional regulation via serotonin modulation.
Preclinical studies have demonstrated the ability of GLP-1 agonists to decrease the hyperactivity of the mesolimbic dopamine system. By reducing drug induced dopamine release GLP-1 agonists were found to reduce the rewarding effects of drugs, though dopamine reuptake was not related to this. Furthermore, the effect of GLP-1 agonists on serotonin pathways holds additional benefits.
Their additional impact on the brain-gut axis highlights another potential avenue for treating addiction. As gut hormones like
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GLP-1 impact brain function, targeting this via agonists could offer new ventures to addiction therapy. According to early research GLP-1 agonists were used for reducing food cravings and stop relapse by influencing neural circuits beyond the dopamine and serotonin pathways, which are known to be involved in stress and anxiety responses.
However, robust clinical trials are essential to confirm long-term efficacy, define optimal patient populations, and address potential tolerance development. Confirming long-term efficacy of GLP-1 agonists, understanding person to person variations in response, and defining the most effective patient populations are all critical areas requiring additional investigation. As research progresses, GLP-1 agonists could revolutionize SUD treatment by offering a comprehensive, multifaceted strategy to address both biological and psychological aspects of addiction.
Future research should prioritize clinical trials exploring the efficacy of GLP-1 agonists across diverse SUDs, including opioid, stimulant, and alcohol dependence. Personalized medicine approaches, leveraging GLP-1 receptor polymorphisms, could optimize treatment outcomes by tailoring therapies to individual patient needs. Combination strategies that integrate GLP-1 agonists with established behavioral and pharmacological treatments could also enhance their therapeutic potential.
GLP-1 receptor agonists represent a novel and promising approach to treating SUD by targeting addiction-related neurochemical imbalances. GLP-1 agonists have the potential to revolutionize the treatment landscape for Substance Use Disorders (SUD), addressing one of the most challenging public health crises of our time. These medications, traditionally used to manage diabetes and obesity, have
shown promising effects in reducing cravings and addictive behaviors in preclinical and clinical studies. By modulating brain reward pathways, GLP-1 agonists could offer a groundbreaking approach to addiction treatment, providing new hope to millions worldwide who are struggling with the devastating impacts of SUD.
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Evaluating Barriers to Treatment for Substance Use Disorder in Correctional Facilities in the United States
Authors: Parul Chhatpar, DO, UMass Chan Medical School, Worcester, MA
Mohit Chhatpar, DO, Indiana Regional Medical Center, Indiana, PA
Nancy Le, BS, William Carey University College of Osteopathic Medicine, Hattiesburg, MS
Braden Staats, Pennsylvania Western University, California, PA
Isaiah Woodard, BS, Indiana University of Pennsylvania, Indiana, PA
Introduction
Substance use disorders (SUD) create a significant public health challenge, particularly in correctional facilities where the prevalence of substance addiction is high. In 2007-2009, research from the National Inmate Surveys reported that 58% of state prisoners and 63% of sentenced jail inmates met the criteria for drug dependence or abuse. Despite this high need for treatment, access to effective interventions such as medication-assisted treatment (MAT) remains limited inside these facilities. Only 43.8% of the 1028 jails surveyed across the nation offered any form of treatment for opioid use disorder. And of those that did, only 12.8% of them offered the treatment to anyone who had the disorder.
Lack of treatment perpetuates cycles of addiction, incarceration, and recidivism. Prior studies indicate that 68% of drug offenders are rearrested within three years of release (Belenko et al., 2013). This underscores the critical need for effective SUD treatment programs within correctional facilities. The impact of methadone treatment is effective in reducing postrelease criminal re-offending and correctional readmission (FarrellMacDonald et al., 2014). Patients in the Methadone Maintenance Treatment (MMT) group had a 65% lower risk of returning to custody than both the group that terminated treatment post-release and the nonmethadone control group.
This study explores the key barriers to SUD treatment in correctional facility settings. These barriers include limited access to MAT, cost and regulatory obstacles, staffing and training problems, and stigma that surrounds the treatment. The need for improvements in treatment delivery is highlighted, along with proposed future directions for addressing these challenges.
Materials and Methods
This literature review examines current literature through a comprehensive search of PubMed, Google Scholar, National Institute of Health, and Bureau of Justice Statistics databases. Literature published from 2004 and onward
was the primary focus. The search utilized key terms such as “opioids,” “overdose,” “medications for opioid use disorders,” “substance use disorder,” “prisons,” “jails,” and “correctional facilities” to identify relevant studies conducted within the past 20 years. Selected publications were carefully evaluated to ensure their relevance and quality.
Articles were excluded based on the following criteria:
• Not in English
• Published prior to 2004
• Not published in a peerreviewed journal
• Is an opinion piece, commentary, or published letter
availability inside correctional facilities is low. According to national surveys, less than half of the jails in the United States offer any form of MAT, and only a small percentage of the ones that do offer MAT are given to incarcerated individuals. Within the facilities that have MAT, there are regulations that only offer it to specific populations including pregnant women or individuals who were already receiving MAT before their arrest (EF Balawajder, et al., 2024). This restriction is largely a consequence of limited resources, including the capacity to provide medications like methadone, as well as restrictive policies that prioritize certain groups over others. State prisons,
Lack of treatment perpetuates cycles of addiction, incarceration, and recidivism. Prior studies indicate that 68% of drug offenders are rearrested within three years of release (Belenko et al., 2013).
Results
The four major themes that arose were limited access to medications, staffing and training challenges, cost and regulatory issues, and stigma and policy barriers. Table I shows the details of the included studies and the coding of the thematic categories related to barriers.
Table 1. Description of Studies Included in Scoping Review on Barriers and Facilitators of Implementation of MOUD within the Criminal Justice System or with Criminal Justice Populations
1. Limited Access to Medications:
One of the most significant barriers to effective SUD treatment in correctional facilities is the limited availability of MAT. This is particularly important with regard to opioid use disorders. MAT has been proven as an effective treatment option for SUD and opioid use disorders (OUD) but the treatment
when MAT is offered, these operational difficulties persist (Carlin, 2005). Dispensing methadone in prison settings is difficult due to the difficulty of obtaining the necessary licensure to operate an opioid treatment program (OTP). The process is lengthy and inconvenient. The few licensed OTPs operating out of jail or prison settings reported that the process took years, which is too long given the urgency of the overdose crisis (Johns Hopkins Bloomberg School of Public Health, 2021).
3. Cost and Regulatory Issues:
which house individuals for longer periods of time, are better equipped to offer intense SUD treatment as they have more time to assess, plan, and deliver the treatment. Meanwhile, in county jails, the individuals are often incarcerated for a short period of time which complicates the delivery of effective treatment (Zaller et al., 2022).
2. Staffing and Training Challenges:
Another significant challenge that prevents adequate SUD treatment is the ability to find and maintain trained staff members to employ the treatment. According to the JAMA Network Open and NIH’s National Institute on Drug Abuse (NIDA), the most common reason for not offering medications for opioid use disorder was the lack of adequate licensed staff which was indicated by 49.8% of jails. Even
The lack of funding is another challenge barring effective care. In 2015, the annual state budget for an incarcerated individual in California was $20,000, compared to approximately $2200 in Louisiana (Pew Charitable Trusts, 2017). The drastic differences in funds allocated across states results in variations in staff training and ultimately, poor SUD treatment. This leads to jails and prisons relying on partnerships with community-based OTPs. However, these partnerships can be logistically challenging and financially impractical, especially to rural correctional facilities where there is no close OTP that can provide affordable services including onsite methadone dispensing (Johns Hopkins Bloomberg School of Public Health, 2021).
4. Stigma and Policy Barriers:
In addition to the operational and logistical challenges, stigma and negative perceptions about MAT contribute to the reluctance of both correctional staff and incarcerated individuals to embrace MAT as a treatment option. Both participants and staff report “extremely” negative beliefs about methadone maintenance treatment (MMT). Participants also claim to “fear” methadone and feel morally superior because they are “clean” (Azbel, Rosanova, 2017). There are high preferences for
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drug-free treatment, especially in prisons, but also very little knowledge of the benefits of MAT (Friedmann & Hoskinson, Gordon, et al., 2012). Despite there being substantial evidence and literature that supports the benefits of MAT protecting public safety in both correctional facilities and in the community, criminal justice
Overdose is the leading cause of death among people returning to their communities after incarceration. A recent county-level study found that 21% of individuals who died of a fatal overdose had been in jail, a facility for short-term stays, where most people are awaiting trial, sentencing, or serving a short sentence (Victor et al., 2022).
professionals are not always aware of the literature or are not convinced of the findings (Chandler et al., 2004). Criminal justice administrators often discourage the use of buprenorphine injections, a key medication for opioid use disorder (MOUD), due to common misconceptions that it replaces one addiction with another instead of recognizing that it offers therapeutic benefits (Andraka-Christou, Capone, 2018). Furthermore, there is concern that patient health information, such as urine test results used to monitor compliance with MAT, could be used punitively instead of supporting recovery (Andraka-Christou, Capone, 2018). Moreover, substance abuse disorder treatments are perceived as less essential than those of security and supervision. During times of fiscal cutbacks, criminal justice administrators usually cut back the services that are legally discretionary without regard for strategic planning or long-term outcomes. Despite the impressive track record of substance abuse treatments in reducing criminal recidivism, they are not legally mandated in the correctional setting, whereas health and mental health services are. As a result, substance abuse treatment services are among the first to be scaled back or eliminated when criminal justice funds are cut (Chandler et al., 2004).
Discussion
The findings of this review reveal several significant barriers to the implementation of MAT in correctional facilities. Barriers discussed include limited availability, staffing shortages, regulatory challenges, and stigma. These findings
highlight the systemic failure to prioritize the importance of substance abuse disorder treatment, especially among incarcerated individuals.
The limited availability of MAT, especially in county jails and prisons, is a major obstacle in addressing the needs of incarcerated individuals with opioid use disorders. State prisons have more capacity to deliver comprehensive treatment due to longer incarceration periods, but jails often struggle with shorter stays, which limits their ability to provide impactful interventions. Additionally, restrictive policies that limit MAT access to specific populations exacerbate inequities in treatment availability.
Staffing shortages and complex regulatory requirements have created further challenges to MAT implementation. As cited, many facilities report difficulty in obtaining the necessary licensure to operate OTPs. As a result, correctional facilities often rely on communitybased OTPs, which pose logistical and financial challenges, particularly in rural communities where access to such services is limited. These operational hurdles reflect a need for up-to-date processes and additional resources to support the delivery of MAT in the correctional facility setting.
The stigma surrounding MAT also has a significant impact on its acceptance and delivery. Both incarcerated individuals and correctional facility staff have negative attitudes toward MAT and favor drug-free approaches. This resistant attitude toward MAT is a consequence of a lack of knowledge about the long-term benefits of MAT, such as reduced recidivism and improved public safety outcomes. Educational initiatives aimed at addressing these misconceptions could harbor significant change in the stigma associated with MAT and increase its acceptance in correctional settings.
Furthermore, the prioritization and supervision of SUD treatment services reflect the broader systemic issues in correctional policy. During budget cuts, discretionary services like SUD treatment are often among the first to be reduced or eliminated completely. This comes even despite the demonstrated success in reducing criminal behavior. This lack of prioritization underscores the need for a policy shift that recognizes substance use treatment as an essential component of correctional care and not an optional add-on.
Prevention
Addressing and treating substance abuse disorders in the correctional facility setting could be an upstream intervention to combat the opioid crisis. Overdose is the leading cause of death among people returning to their communities after incarceration. A recent county-level study found that 21% of individuals who died of a fatal
overdose had been in jail, a facility for shortterm stays, where most people are awaiting trial, sentencing, or serving a short sentence (Victor et al., 2022). By addressing this issue, there would be a potential decrease in overdose deaths, an increase in community-based treatments, and decreased incarceration rates. As mentioned, results have shown compelling evidence supporting the use of medications for substance abuse disorders (including opioid use disorder) for the currently incarcerated populations. Almost all studies have shown that medication treatment for opioid use disorders that was provided during incarceration led to an increased community-based treatment engagement after the individual was released. There is also evidence that shows that initiating or continuing medication treatment during incarceration is associated with decreased opioid use and overdoses post-release, without increasing criminal involvement (Cates, 2023). The same study has also shown that the rate of recidivism post-incarceration is lower among individuals who were offered buprenorphine (medication to treat OUD) while incarcerated.
Future Directions
Future research is essential to advance the understanding and implementation of effective SUD treatments within correctional facilities. One area with top priority is developing a standardized process for assessing, planning, and delivering SUD treatment in these settings. By establishing clear and consistent guidelines it would ensure equitable and effective treatment across facilities and improve the outcomes for incarcerated individuals.
Another important area is the evaluation of training programs for licensed staff. Effective training protocols that equip professionals to provide safe SUD treatment are necessary to
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meet the needs of individuals in correctional settings. It is also important to address the stigma associated with SUD treatment for both criminal justice professionals and inmates. Ways of reducing stigma surrounding SUD treatment include educational initiatives, cultural shifts inside correctional facilities, and advocacy to normalize the treatment.
A longitudinal investigation should be completed to provide data about treatment delivery and effectiveness. Such research should examine treatment histories prior to incarceration, track progress during incarceration, and conduct follow ups post release. This would provide comprehensive insight on the effectiveness of intervention across the criminal justice continuum (Zaller et al., 2022). This data would help identify patterns and gaps in care, and also areas in need of improvement when it comes to treatment delivery.
Research is also needed to identify optimal strategies for blending public health and public safety approaches in the treatment and supervision of offenders with co-occurring disorders (COD). Efforts to clarify the operation elements of COD treatment in the criminal justice system are also in demand. This includes the examination of the impact of factors such as organization, management, and financing of treatment and aftercare services on treatment outcomes related to mental health, substance use, criminal behavior, physical health, housing, employment, parenting, and victimization (Chandler et al., 2004).
Conclusion
This review highlights the important need to address the barriers that limit the availability and effectiveness of medications for addiction
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treatment (MAT) in correctional facilities. Despite the proven benefits of MAT in reducing substance use, recidivism, and overdose rates, its implementation remains very inconsistent and is constantly hindered by limited access, operational challenges, stigma, and policy constraints. Addressing these barriers is imperative not only for improving the health and rehabilitation of incarcerated individuals but also for reducing the broader societal impacts of the opioid crisis including overdose deaths and criminal activity.
There is a profound need for an immediate change in attitudes within correctional systems with regards to MAT. This change needs to see a view where substance abuse treatment is recognized as an integral component of public health rather than an accessory service. By adopting standardized treatment protocols, investing in staff training, reducing stigma, and integrating public health strategies within criminal justice policies, correctional facilities can see an enhancement in treatment access and effectiveness.
Ultimately, improving the current standard for SUD treatment in correctional facilities is a must. By improving the standard, an opportunity is offered to break the cycle of addiction and incarceration. Future research and policy reforms should aim to address the gaps identified in this review, which will pave the way for more equitable and effective interventions that prioritize the rehabilitation and long-term recovery of incarcerated individuals.
12. Johns Hopkins Bloomberg School of Public Health. (2021, July). Medications for opioid use disorder in jails and prisons: Moving toward universal access. Bloomberg American Health Initiative. https://www.jhsph.edu/research/ centers-and-institutes/bloomberg-american-health-initiative/ initiatives/addiction-and-overdose/index.html
13. McKillop, M. (2017, December 15). Prison Health Care Spending Varies Dramatically by State. Pew Charitable Trusts. http://pew.org/2ogukvP
14. Victor, G., Zettner, C., Huynh, P., Ray, B., and Sightes, E. (2022) jail and overdose: assessing the community impact of incarceration on overdose. Addiction 117: 433–441. https://doi.org/10.1111/add.15640
15. Zaller, N.D., Gorvine, M.M., Ross, J. et al. Providing substance use disorder treatment in correctional settings: knowledge gaps and proposed research priorities— overview and commentary. Addict Sci Clin Pract 17, 69 (2022). https://doi.org/10.1186/s13722-022-00351-0
Illicit Stimulants and Rising Cardiovascular Mortality: Action Required
by Rebecca Arden Harris, MD, MSc, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania
Illicit stimulants— methamphetamine and cocaine—pose significant risks to public health. Both drugs are cardiotoxic: they elevate myocardial oxygen demand via sympathetic activation and simultaneously reduce supply through vasoconstriction, creating conditions conducive to ischemia, infarction, and arrhythmias. Even in individuals without conventional metabolic risk factors, stimulants promote cardiovascular disease (CVD) progression by inducing myocardial remodeling, which increases susceptibility to arrhythmias and contributes to the development of cardiomyopathy and heart failure. Prolonged use further raises the risk of hypertension, coronary artery disease, coronary vasospasm, and stroke1-11 (Figure 1).
Despite well-documented risks, stimulant use remains prevalent. According to the 2023 National Survey on Drug Use and Health, 5.0 million individuals aged 12 and older reported using cocaine in the past year, and 2.6 million reported methamphetamine use.12 The health consequences of this widespread use are reflected in mortality data. Between 2014 and 2023, overall cardiovascular disease (CVD) mortality remained relatively stable, yet age-adjusted CVD death rates involving stimulants rose by 136%. The impact differed by substance: methamphetamine-related CVD fatalities surged by 232%, while
those linked to cocaine increased by 80%. Among stimulant-related CVD deaths, cerebrovascular disease showed the most rapid rise (233%), followed by hypertensive (155%) and ischemic heart disease (100%).13
has been shown to result in positive cardiac remodeling and improved outcomes, highlighting the potential reversibility of some stimulantinduced cardiac damage. 14 This supports a more patient-centered
According to the 2023 National Survey on Drug Use and Health, 5.0 million individuals aged 12 and older reported using cocaine in the past year, and 2.6 million reported methamphetamine use.12
Over the same decade, stimulantinvolved CVD resulted in 965,637 years of life lost (YLL). Males (687,430 YLL), non-Hispanic White individuals (511,120 YLL), and individuals aged 45-64 (626,933 YLL) suffered the greatest losses.13 These pattens reveal a critical gap in substance use disorder (SUD) interventions, as cardiovascular screening and management are rarely integrated into SUD programs.1
While total abstinence from illicit stimulant use has historically been the primary goal of treatment, emerging evidence suggests that reductions in use may be associated with meaningful CVD improvements in health and recovery among people with stimulant use disorder. Importantly, cessation of methamphetamine use
approach to defining treatment success, recognizing that harm reduction can yield tangible cardiovascular and overall health benefits.
Integrating Cardiology into Addiction Treatment
An effective response requires integration of cardiovascular prevention and treatment into addiction care models:
• Screening and Risk Stratification: Routine cardiovascular risk assessments—including blood pressure measurement, ECG for arrhythmia detection (especially in cocaine users), and echocardiography to evaluate cardiomyopathy (particularly in methamphetamine users)— should be standard at treatment
entry and during acute presentations.
• Cardioprotective Pharmacotherapy: Evidencebased therapies such as antihypertensives, statins, and low-dose aspirin should be deployed for higher-risk individuals to aggressively manage cardiovascular risks associated with stimulant use.
• Lifestyle Interventions: Smoking cessation, nutritional counseling, and physical activity programs should be integrated into addiction treatment settings to address modifiable cardiovascular risk factors.
• Contingency Management: The most effective behavioral treatment for stimulant use disorder, contingency management uses incentives (e.g., vouchers for drug-negative tests) to promote abstinence or reduced use, safer practices, and treatment engagement. While typically not used for cardiovascular care, it holds potential to encourage participation in screening and early intervention.15-17
• Pharmacological Treatment: No FDA-approved medications currently exist for cocaine or methamphetamine use disorder.18
• Patient Education: Counseling should emphasize the acute and
continued on next page
Figure 1
chronic cardiovascular risks of cocaine and methamphetamine use, including the potential for methamphetamine cessation to reverse cardiac damage, thereby empowering individuals to engage in sustained recovery.
Addressing the link between stimulant use and cardiovascular health is key to reducing preventable deaths and improving outcomes for people with stimulant use disorders.
Policy Implications
Addressing the growing cardiovascular complications and mortality associated with stimulant use requires a coordinated and multifaceted approach. To improve outcomes for individuals with stimulant use disorders, we must integrate routine cardiovascular
References:
1. Riley ED, et al. Stimulant Use and Chronic Cardiovascular Disease. J Gen Intern Med. 2023. doi:10.1007/ s11606-023-08072-z [PMC10110775]
2. Kevil CG, Goeders NE, Woolard MD, Bhuiyan MS, Dominic P, Kolluru GK, Arnold CL, Traylor JG, Orr AW. Methamphetamine Use and Cardiovascular Disease. Arterioscler Thromb Vasc Biol. 2019;39(9):1739-46. Epub 20190821. doi: 10.1161/atvbaha.119.312461. PubMed PMID: 31433698; PMCID: PMC6709697.
3. Havakuk O, Rezkalla SH, Kloner RA. The Cardiovascular Effects of Cocaine. J Am Coll Cardiol. 2017;70(1):101-13. doi: 10.1016/j. jacc.2017.05.014. PubMed PMID: 28662796.
4. Kozor R, Grieve SM, Buchholz S, Kaye S, Darke S, Bhindi R, Figtree GA. Regular cocaine use is associated with increased systolic blood pressure, aortic stiffness and left ventricular mass in young otherwise healthy individuals. PLoS One. 2014;9(4):e89710. Epub 20140409. doi: 10.1371/journal.pone.0089710. PubMed PMID: 24717541; PMCID: PMC3981670.
5. Kim ST, Park T. Acute and Chronic Effects of Cocaine on Cardiovascular Health. Int J Mol Sci. 2019;20(3). Epub 20190129. doi: 10.3390/ijms20030584. PubMed PMID: 30700023; PMCID: PMC6387265.
6. Zhao SX, Deluna A, Kelsey K, Wang C, Swaminathan A, Staniec A, Crawford MH. Socioeconomic Burden of Rising Methamphetamine-Associated Heart Failure Hospitalizations in California From 2008 to 2018. Circ Cardiovasc Qual Outcomes. 2021;14(7):e007638. Epub 20210713. doi: 10.1161/CIRCOUTCOMES.120.007638. PubMed PMID: 34256572.
7. Arenas DJ, Beltran S, Zhou S, Goldberg LR. Cocaine, cardiomyopathy, and heart failure: a systematic review and meta-analysis. Sci Rep. 2020;10(1):19795. Epub 20201113. doi: 10.1038/s41598-020-76273-1. PubMed PMID: 33188223; PMCID: PMC7666138.
screening into addiction treatment programs and develop collaborative care models that bring together addiction and cardiology specialists.19
Successful implementation will require overcoming several challenges. Addiction treatment programs often lack the resources and trained personnel needed to conduct thorough cardiovascular assessments. Funding mechanisms should support training for addiction treatment staff in basic cardiovascular screening, equip programs with blood pressure monitors, electrocardiogram machines, and point-of-care testing devices for cholesterol and blood glucose, and foster partnerships with local cardiology providers for consultation and support. Patients may also be hesitant to engage in additional medical care, particularly if they perceive it as burdensome or stigmatizing. Patient education materials should clearly communicate the benefits
8. Coffin PO, Suen LW. Methamphetamine Toxicities and Clinical Management. NEJM Evid. 2023;2(12):EVIDra2300160. Epub 20231128. doi: 10.1056/EVIDra2300160. PubMed PMID: 38320504; PMCID: PMC11458184.
9. Batra V, Murnane KS, Knox B, Edinoff AN, Ghaffar Y, Nussdorf L, Petersen M, Kaufman SE, Jiwani S, Casey CA, Terhoeve S, Alfrad Nobel Bhuiyan M, Dominic P, McNeil S, Patterson J, 2nd. Early onset cardiovascular disease related to methamphetamine use is most striking in individuals under 30: A retrospective chart review. Addict Behav Rep. 2022;15:100435. Epub 20220518. doi: 10.1016/j.abrep.2022.100435. PubMed PMID: 35620216; PMCID: PMC9127267.
10. Schwarzbach V, Lenk K, Laufs U. Methamphetamine-related cardiovascular diseases. ESC Heart Fail. 2020;7(2):407-14. Epub 20200117. doi: 10.1002/ehf2.12572. PubMed PMID: 31950731; PMCID: PMC7160483.
11. O’Keefe EL, Dhore-Patil A, Lavie CJ. Early-Onset Cardiovascular Disease From Cocaine, Amphetamines, Alcohol, and Marijuana. Can J Cardiol. 2022;38(9):134251. Epub 20220714. doi: 10.1016/j. cjca.2022.06.027. PubMed PMID: 35840019.
12. SAMHSA. Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). In: Center for Behavioral Health Statistics and Quality SAMHSA, 2024.
13. Harris R, Khatana SAM, Glei DA, Long JA. Stimulant-Involved Cardiovascular Disease Mortality and Life Years Lost, 2014–2023. Substance Use: Research and Treatment. 2025 (in press).
14. Bhatia HS, Nishimura M, Dickson S, Adler E, Greenberg B, Thomas IC. Clinical and echocardiographic outcomes in heart failure associated with methamphetamine use and cessation. Heart. 2021 May;107(9):741-747. doi: 10.1136/heartjnl-2020-317635. Epub 2020 Oct 5. PMID: 33020227; PMCID: PMC8842989.
of early detection and intervention, and care delivery should be sensitive, non-judgmental, and seamlessly integrated into existing treatment workflows. Finally, access to specialized cardiac care is often limited, particularly in rural communities. Telehealth and collaborative care models can help bridge this gap, allowing specialists to provide remote consultation and support to primary care and addiction treatment providers.
Addressing the link between stimulant use and cardiovascular health is key to reducing preventable deaths and improving outcomes for people with stimulant use disorders. This requires collaborative action: addiction and cardiac care providers implementing coordinated protocols, policymakers prioritizing funding for sustainable, integrated treatment models, and researchers developing and refining targeted interventions.
15. Khazanov GK, McKay JR, Rawson R. Should contingency management protocols and dissemination practices be modified to accommodate rising stimulant use and harm reduction frameworks? Addiction. 2024 Sep;119(9):1505-1514. doi: 10.1111/add.16497. Epub 2024 Apr 16. PMID: 38627885.
16. Rawson R, Khazanov GK, McKay JR. Research is needed to guide contingency management implementation across populations and settings. Addiction. 2024 Sep;119(9):1525-1526. doi: 10.1111/add.16614. Epub 2024 Jul 9. PMID: 38979697.
17. Leyde S, Abbs E, Suen LW, Martin M, Mitchell A, Davis J, Azari S. A Mixed-methods Evaluation of an Addiction/Cardiology Pilot Clinic With Contingency Management for Patients With Stimulant-associated Cardiomyopathy. J Addict Med. 2023 May-Jun 01;17(3):312-318. doi: 10.1097/ADM.0000000000001110. Epub 2022 Dec 5. PMID: 37267175; PMCID: PMC10242504.
18. Clinical Guideline Committee (CGC) Members; ASAM Team; AAAP Team; IRETA Team. The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. J Addict Med. 2024 May-Jun 01;18(1S Suppl 1):1-56. doi: 10.1097/ADM.0000000000001299. PMID: 38669101; PMCID: PMC11105801.
19. Davis JD, Bepo L, Suen LW, McLaughlin MM, Adamo M, Abbs E, Lemke G, Azari S. Implementing Heart Plus: Design and Early Results of a Novel Comanagement Clinic for Patients With Stimulant-associated Cardiomyopathy. J Card Fail. 2024;30(7):86976. Epub 20231119. doi: 10.1016/j. cardfail.2023.10.481. PubMed PMID: 37984791.
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As of 2019, drug overdoses are a
leading cause of injury-related deaths in the US.1
In 2022, 81.8% of drug overdose deaths involved at least one opioid. Illegally made fentanyls were the most commonly involved drug class and were found in 74.6% of overdose deaths. 2
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