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Clinical Toxicology Intelligence

Issue

#16

August 2026

One in Three Patients Starting Buprenorphine Gets a New Anxiety Diagnosis in Year One. Telehealth Patients Are Less Likely to Receive One.

In a pharmacoepidemiology study of 3,054 commercially insured patients initiating buprenorphine, Varisco et al. found that 35% received a new anxiety or stress-related diagnosis within the first year of treatment, with a median time to diagnosis of 199 days. The study used a large insurance claims database and adjusted for key baseline covariates, including prior mental health diagnoses.

The telehealth finding is where interpretation gets harder. Patients who initiated buprenorphine via telehealth were significantly less likely to receive a new anxiety or stress-related diagnosis in year one (adjusted HR 0.78; 95% CI 0.62–0.98). That finding runs against the expectation: telehealth access was supposed to reduce barriers, not result in fewer diagnoses. The authors flag two competing explanations directly: either telehealth patients are genuinely doing better, or virtual encounters are less likely to surface anxiety symptoms that would have been identified in person. The design cannot distinguish between the two.

The clinical implication is the same regardless of which explanation is correct: buprenorphine induction is not just a prescribing encounter. For a large proportion of patients, the first year of treatment is also the period when anxiety and stress-related conditions first come to clinical attention. Whether that is new pathology, unmasked pathology, or recognized-for-the-first-time pathology, it needs to be on the screen. Source: Varisco TJ, Sadeghi A, Loera L, et al. Drug Alcohol Depend. 2026;287:113301. doi:10.1016/j.drugalcdep.2026.113301

ASAM Criteria 4th Ed. / Correctional SUD

Public Comment Window Closes August 31: ASAM Criteria Vol. 3, Correctional Settings and Reentry.

ASAM is finalizing Volume 3 of the 4th Edition of The ASAM Criteria, the standards that will govern SUD placement and continuing-care decisions for justice-involved and reentering patients. The public comment period closes August 31. Volume 3 is the standard that drug courts, correctional facilities, and reentry programs will be citing when they make clinical placement decisions. How methadone and buprenorphine dose continuity across the jail-to-community transition is framed in these criteria has direct consequences for patients at the highest risk of overdose death in the post-release window.

The overdose risk in the first two weeks after release from incarceration is 10 to 40 times higher than in the general population, and the single most evidence-based intervention for that window is MOUD continuity. Medication continuity at release is the clinical point where these standards will either help or fall short.

Comment at: asam.org/asam-criteria  ·  Draft framework PDF linked on that page  ·  Deadline: August 31, 2026

Overdose Surveillance / CDC

Third Consecutive Year of Declining Overdose Deaths. Virginia Down 23% in 2025.

CDC provisional data for the 12 months ending February 2026 show 68,641 predicted overdose deaths, a 12.1% decline from the prior year. National Fentanyl Prevention and Awareness Day (August 21) highlighted the broader picture: synthetic opioid deaths other than methadone fell 22% to 38,084 in 2025 versus 48,913 in 2024; total overdose deaths fell approximately 14% to 69,973. Virginia's preliminary 2025 figure of 1,197 deaths represents a 23% decline from 2024.

Sources: CDC overdose data portal; White House Fentanyl Prevention and Awareness Day release (Aug 21, 2026)

Am J Drug Alcohol Abuse  ·  Nationally Representative Survey  ·  August 2026

99% of Recovery Housing Test Residents. 94% Evict Residents Who Fail. A False Positive Here Has Consequences.

Mericle et al. surveyed a nationally representative sample of 838 recovery residences and found near-universal drug testing (99%) paired with near-universal eviction policies for residents who test positive (94%). 97% require abstinence. Only 56% accept residents on psychiatric medications. In the subset of primarily 12-step-oriented residences, acceptance of residents on methadone was significantly lower (OR 0.41, p=.003), and acceptance of psychiatric medications was also lower (OR 0.52, p=.006). The same residences were more likely to keep naloxone on site (OR 10.38, p=.010). doi:10.1080/00952990.2026.2705219

EClinicalMedicine  ·  Retrospective Cohort  ·  n=295,728  ·  August 2026

A Positive Fentanyl UDT Does Not Tell You the Source. A 295,000-Patient Study Quantifies What That Distinction Actually Means.

Lee et al. used the Epic Cosmos EHR (over 300 million patients) to analyze longitudinal fentanyl exposure patterns in 295,728 patients, classifying source as medical or illicit by linking UDT results to fentanyl medication records via a time-window algorithm. Illicit-source initiation carried adjusted 30-day hazard ratios of 2.99 for overdose, 1.96 for abuse diagnosis, and 3.05 for dependence diagnosis. The outcome data are striking. The methodology is important to understand: the source classification rests on an algorithm, not a validated attribution method, and miscategorization is not random. A fentanyl-positive UDT without a same-system prescription record could reflect illicit use, a prescription filled elsewhere, inpatient procedural administration, or analog cross-reactivity. The study's authors make this explicit. doi:10.1016/j.eclinm.2026.104141

From Bill

"The overdose numbers are moving in the right direction for the third year running, and that matters. It represents real lives. But 16% of people who need treatment are getting it, and buprenorphine prescription abandonment rates are rising at the same time that 40% of major chain pharmacies decline to stock it. Declining deaths without expanding access is not a solved problem. It is a problem that is getting better in some ways while remaining fundamentally unsolved in others."

Dr. William Bundy Jr., PharmD  ·  ToxiPharm LLC

Tox Pearl #16 is out.

A positive fentanyl UDT does not tell you whether the source is prescribed or illicit. This Pearl explains why, what the new Epic Cosmos data show about the clinical stakes, and what a court or clinician can and cannot conclude from a fentanyl-positive result. Free one-page clinical reference at toxipharm.org.

Questions about a drug test result? Consulting on an OTP or drug court program?

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