Faculty Bibliography

BACKGROUND:Methadone is the gold standard treatment for opioid use disorder (OUD). In the U.S., methadone is usually only available through licensed opioid treatment programs (OTPs), but a 2021 federal rule provided an opportunity for OTPs to provide methadone on mobile medication units (MMUs). MMUs operate under the license of an OTP and are subject to complex regulatory requirements. New York State provided grant funding to support OTPs to adopt MMUs, aligned with the broader goal to improve methadone access statewide. This study explored barriers and facilitators to MMU implementation across New York State from the perspectives of treatment staff and administrators. METHODS:We conducted semi-structured interviews between June 2024 and June 2025 with 16 staff from four OTPs that adopted MMUs and one residential treatment program served by an MMU. Interviews were audio-recorded, transcribed, and analyzed using a hybrid deductive-inductive thematic analysis approach to identify implementation barriers and facilitators. RESULTS:Staff described a variety of potential models for using MMUs to expand access. In New York City, MMUs were used to serve a residential substance use program. In upstate NY, MMUs were deployed to reduce travel distance in counties with few OTP options. Key facilitators of MMU implementation included leadership persistence in the face of community pushback, creativity and workarounds in the face of logistical hurdles, and support from the state agency. Key barriers included community resistance to MMUs, unclear or inconsistent guidance from the Drug Enforcement Administration, and a variety of operational challenges, such as vehicle maintenance and workforce shortages. Staff generally were positive about the opportunity to use MMUs to address access challenges. CONCLUSIONS:MMUs provide a novel approach to expand methadone access, particularly to populations not currently served by brick-and-mortar OTPs. Early implementers can provide important lessons about how to manage start-up challenges, which can guide later adopters.

Methadone is a highly effective treatment for opioid use disorder. However, its public health impact in the U.S. has long been constrained by strict regulations requiring dispensing through specialty opioid treatment programs (OTPs). In 2021, the U.S. Drug Enforcement Administration authorized mobile medication units (MMUs) to dispense methadone in community settings, raising hopes that mobile delivery could expand access for underserved populations. This commentary examines New York State's early experience implementing MMUs as a case study of both the opportunities and persistent challenges associated with this care delivery model in the U.S. We discuss how burdensome methadone requirements, high start-up and operating costs, complex staffing and logistical burdens, community opposition, and a continued emphasis on diversion control over patient access have limited the ability to effectively scale MMUs as a low-threshold treatment option. Although MMUs have and will continue to improve convenience and access for some patients, their potential to substantially improve geographic access, provide lower-threshold care, and deliver comprehensive OUD services is inhibited by the broader U.S. "methadone exceptionalism" framework, which silos methadone as a separate and more restrictive treatment modality requiring excessive vigilance and oversight . We argue that without greater regulatory clarity, flexibility, and alignment with patient-centered care goals, MMUs may likely remain a welcomed but modest, rather than transformative, innovation in addressing methadone gaps in the United States.

BACKGROUND:The illicit drug landscape in South America is going through a major shift. The appearance of Tusi (or "pink cocaine"), a mixture often containing ketamine and MDMA, along with the growing presence of synthetic opioids like fentanyl and nitazenes, signals a new chapter in the region's drug use, which has been traditionally dominated by alcohol, cannabis, and cocaine. MAIN BODY/METHODS:Drawing on data on seizures, forensic analyses, warning systems, and surveys from Brazil, Chile, and Colombia, this perspective highlights three movements of the drug supply: non-prescribed and synthetic opioids, ketamine, and Tusi. We also elaborate on their unique public health challenges. Brazil and Chile have seen an increase in non-prescribed opioid use, some of them diverted from healthcare, accompanied by seizures of illicit fentanyl and the discovery of nitazene production in Brazil in May 2025. Colombia, while historically experiencing low opioid use, has documented fentanyl analogs in ketamine and MDMA/Ecstasy samples, mixed with various other contaminants, thus increasing risks among people who use them. Concurrently, ketamine and Tusi use are expanding rapidly across all three countries, particularly among nightclub attendees and youth with criminal-legal involvement. Tusi's unpredictable composition poses heightened overdose risks, especially in settings lacking drug-checking and overdose-prevention education and programs. Furthermore, South America has minimal opioid agonist therapy coverage, limited naloxone access, and underdeveloped harm reduction systems. CONCLUSION/CONCLUSIONS:The emergence of synthetic opioids, ketamine, and Tusi signals a new synthetic drug phase in South America's supply. The convergence of traditional drugs with potent new substances poses important health-related harms. Strengthening regional surveillance, toxicological monitoring, and harm reduction services are urgently needed. Coordinated international research and public health responses will be essential to prevent a drug crisis.

OBJECTIVES/OBJECTIVE:Policy reforms are being considered to increase methadone treatment (MT) access for opioid use disorder in the United States. Proponents of more structured MT reference risks of diversion, including non-prescribed use or redistribution of methadone, and overdose as arguments for limiting access to specialty settings. However, the scientific evidence behind these claims has not been thoroughly reviewed. METHODS:We conducted a narrative review of studies on methadone diversion, diverted methadone-involved overdoses, and how these compare in countries with specialty-care-only policies (methadone dispensed only through regulated treatment programs) versus general physician-prescribing policies (physicians prescribe methadone in office-based settings). A narrative approach was chosen, given substantial heterogeneity in study designs, diversion definitions, outcome measures, and data sources. We synthesize and discuss findings from international papers published before October 2025. RESULTS:We identified 29 articles studying methadone diversion or diverted methadone-involved overdoses in 7 countries. Lifetime methadone diversion occurrence varied between 6% and 68%, and using diverted methadone occurrence varied between 22% and 88%. Diverting methadone was most often done to help sick friends/partners. Common reasons for using diverted methadone were preventing withdrawal and avoiding opioid use. Three studies found no association between self-reported diverted methadone use and increased individual-level risk of overdose. CONCLUSIONS:The link between specialty-care-only policies and lower diversion and overdose risk is not supported by the reviewed literature. Policymakers should weigh diversion risks against benefits of lives saved through expanded MT access. Further research is needed to better understand the circumstances related to diverted methadone and inform policy-making that appropriately mitigates risks.

INTRODUCTION/BACKGROUND:A 2021 federal rule permits opioid treatment programs (OTPs) to provide methadone through mobile medication units (MMUs), creating an opportunity to provide medication for people in residential care facilities. We used simulations to quantify the potential of MMUs to expand methadone access to people residing in residential substance use treatment facilities (RTF), skilled nursing facilities (SNF), and nursing facilities (NF) in New York State under different scenarios. METHODS:For each facility (RTF, SNF, and NF), a need score was created using three items: facility opioid use disorder (OUD) population, driving distance to nearest OTP, and county overdose mortality rate. We then demonstrated potential patient reach following the launch of 50 hypothetical MMUs making one stop per day to the highest need facilities. In refinements, we examined three additional scenarios involving more daily stops and prioritizing rural areas. RESULTS:Our sample included 3214 people with OUD estimated to be housed in 1052 facilities in New York, with the majority in RTFs (51.5%). The demonstrated percentage of OUD population served ranged from 23.5% to 35.8%, and the percentage of facilities served ranged from 23.8% to 37.4%. Each scenario reached a large percentage of rural facilities (73-76%). Prioritizing rural facilities decreased the proportion of OUD population served (10% reduction) but did not substantially increase driving time. Allowing multiple stops increased the proportion of OUD population served (32-36% vs. 24-26%). CONCLUSIONS:Using methods based on location information and spatial relationships, state officials can develop priorities and assess tradeoffs of MMU deployment and distribution strategies.

BACKGROUND:Individuals with opioid use disorder (OUD) may experience fewer barriers to treatment following incarceration if offered in-jail medications for OUD (MOUD). We aimed to identify care trajectories of community OUD treatment after incarceration and examine the association between receiving in-jail MOUD and experiencing specific community treatment trajectories. METHODS:This retrospective cohort study using matched New York City (NYC) health care administrative data included adults with OUD incarcerated on or after May 2011 and discharged during 2014-2017. We defined states of community OUD treatment at the weekly level over one year following index jail discharge and performed state sequence analysis (SSA) to identify trajectories of treatment after jail and assessed the influence of receiving in-jail MOUD on treatment trajectories. RESULTS:Of 14,923 eligible individuals, 26.2% received in-jail MOUD. SSA identified eight clusters of community care trajectories: continuous methadone treatment (9.7%), methadone treatment discontinuation (3.7%), methadone treatment and reincarceration (6.7%), methadone treatment initiation (4.8%), continuous reincarceration (3.5%), short reincarceration with little community treatment (20.3%), long reincarceration with little community treatment (7.0%), and no community OUD treatment or reincarceration (44.5%). Receiving in-jail MOUD was associated with belonging to the continuous methadone treatment cluster compared to the no community OUD treatment or reincarceration cluster (adjusted OR: 12.5, 95% CI: 9.9-15.7). CONCLUSION/CONCLUSIONS:We identified eight unique patterns of community OUD treatment after jail release. Receipt of in-jail MOUD was associated with belonging to the continuous methadone treatment cluster. These findings suggest that provision of in-jail MOUD could improve methadone uptake in the community.

Despite robust evidence that medications for opioid use disorder (MOUD) reduce overdose and mortality, substantial care gaps remain following opioid-related hospital encounters. The opioid use disorder (OUD) Cascade of Care framework conceptualizes progression from identification to treatment initiation and retention, yet limited research has examined how real-world OUD treatment trajectories unfold, particularly across treatment episodes and multiple care settings. This paper describes an NIH-funded study protocol (1R01DA061367-01A1) to conduct a longitudinal observational study using linked administrative data across New York City to characterize OUD treatment trajectories following opioid-related hospital encounters. Using the OUD Cascade of Care framework, we will apply state sequence analysis to identify common patterns of OUD treatment engagement in the year following hospitalization, including transitions between treatment modalities and periods in and out of care. We will examine how care trajectories vary by individual and neighborhood characteristics, and assess associations between trajectories and key outcomes, including rehospitalization, overdose, and mortality. By applying novel data-driven longitudinal methods, this study will advance understanding of the complex, non-linear nature of OUD treatment engagement. Findings will inform health system and policy efforts to identify populations at elevated risk, hospital-based interventions, and opportunities to address gaps in care to reduce overdose-related harms.

BACKGROUND:Overdose rates in the U.S. rose dramatically during the COVID-19 pandemic. Well-documented racial and sociodemographic inequities in the impact of the pandemic suggest the potential for similar inequities for overdose. Our objective was to identify subgroups of New York State Medicaid enrollees who experienced the greatest increases in non-fatal opioid overdose risk following onset of the COVID-19 pandemic. METHODS:Data are from a retrospective cohort of 1,021,889 people enrolled in New York State Medicaid from 2019-2020. To identify subgroups with the greatest increased risk of non-fatal overdose following onset of the COVID-19 pandemic, we used Heterogeneous Treatment Effect (HTE)-Scan, a novel machine learning method developed for accurate and computationally efficient discovery of heterogeneous treatment effects in complex data. RESULTS:In the total sample, risk of non-fatal opioid overdose increased 22% after onset of the pandemic. We also identified two subgroups with elevated risk relative to the total sample: subgroup 1 (Black and Hispanic males aged 45-64 years old with no baseline documentation of opioid use disorder (OUD); N = 53,065) and subgroup 2 (people aged 45-64 years old with documented aged/blind/disabled status and no baseline documentation of OUD; N = 73,694). These subgroups experienced a 54% and 57% increase in non-fatal overdose risk, respectively. CONCLUSIONS:We estimated heterogeneous effects of onset of the COVID-19 pandemic on non-fatal overdose, with elevated risks estimated for older working-aged, structurally disadvantaged adults without documented OUD. These findings illustrate the importance of structural factors in driving heterogeneous risk of overdose following complex social events.

INTRODUCTION/BACKGROUND:The criminal legal system (CLS) is the most common treatment referral source for adolescent cannabis-related problems. Understanding trends in racial/ethnic disparities of CLS-referred treatment could help identify groups in need of additional supports. METHODS:This observational study used repeated cross-sectional data from the Treatment Episode Dataset-Admissions 2010-2022 and Census population denominators to calculate annual specialty CLS-referred cannabis-related treatment admission rates per 10,000 adolescents ages 12-17 by race and ethnicity. Joinpoint models examined trends in CLS-referred treatment rates by race and ethnicity, and group differences in the percent of cannabis admissions referred through the CLS were described. RESULTS:Adolescent cannabis CLS-referred treatment rates decreased overall by 81.6% from 2010 (16.93/10,000) to 2022 (3.11/10,000). Joinpoint models identified different turning points when significant reductions started by race and ethnicity. Compared to non-Hispanic White adolescents across all years, CLS-referred treatment admission rates were higher for American Indian/Alaska Native non-Hispanic adolescents (rate difference [RD]=19.53 95% CI=7.91-31.15) and Black non-Hispanic adolescents (RD=10.14, 95% CI=0.19, 20.08), but not other groups. American Indian/Alaska Native and Black adolescents had higher CLS-referred treatment than white adolescents in 2010 in both absolute and relative terms; differences with wider confidence intervals in 2022 were no longer statistically significant. CONCLUSIONS:CLS-referred cannabis-related treatment admissions decreased substantially across groups over time. High CLS-referral rates among American Indian/Alaska Native and Black non-Hispanic adolescents highlight the importance of distinguishing heterogeneous racial/ethnic groups. Targeted structural interventions are needed to increase non-CLS-related referrals and address cannabis-related treatment gaps in a changing cannabis policy environment.