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Clinical Toxicology Intelligence

Issue

#18

October 2026

One in Thirty-Two Youth with OUD Stay on Medication for Six Months. Here Is Where the Other Thirty-One Go.

Hadland and colleagues followed 229,847 Medicaid-enrolled young people aged 13 to 25 diagnosed with opioid use disorder between 2016 and 2023. Half initiated any treatment within 14 days. A third engaged meaningfully. 15.2 percent ever received medication. 3.1 percent remained on it for 180 days or more. (Hadland SE et al. JAMA Netw Open. 2026;9(10):e2637263.)

The age split is the part that deserves attention. Among adolescents under 18 who engaged with treatment, 6.6 percent received any MOUD. Among those 18 and older, 51.2 percent did. That gap is not biology; it is a structural access problem at every stage: prescriber authorization, pharmacy stocking, guardian consent requirements, and program rules that were designed around adult populations.

For those who did start medication, six-month retention broke down as follows: methadone 26.2 percent, buprenorphine 19.2 percent, extended-release naltrexone 5.8 percent. Methadone outperforming buprenorphine on retention in a national youth cohort is a concrete data point for conversations where a clinician or family assumes buprenorphine is the more manageable first option. It does not mean buprenorphine is wrong; it means the retention comparison is real and should be in the room when medication selection is discussed.

FDA Final Order / Clinical Toxicology Test Systems

FDA Removes 510(k) Premarket Requirement for 14 Clinical Toxicology Test System Types. Oral Fluid Collection Devices Are Not Included.

FDA published a final order on October 6 removing the 510(k) premarket notification requirement for 14 categories of clinical toxicology test systems under 21 CFR 862.3100 through 862.3910 (91 FR 63478, Doc. 2026-20448). The exempted categories are amphetamine, barbiturate, benzodiazepine, cocaine and cocaine metabolite, codeine, LSD, methamphetamine, methadone, methaqualone, morphine, opiate, propoxyphene, cannabinoid, and tricyclic antidepressant test systems.

The exemption applies to test systems labeled for employment and insurance testing and extends to devices intended for federal drug testing programs, subject to 21 CFR 862.9. FDA was explicit that it does not administer or implement federal drug testing programs. It was equally explicit that it has not determined 510(k) is unnecessary for oral fluid collection devices: those remain subject to premarket review even though oral fluid was authorized for regulated workplace use in 2023 and the SAMHSA oral fluid mandatory guidelines are in effect.

Effective: October 6, 2026  ·  91 FR 63478

DEA Correcting Amendment / O-Desmethyltramadol

DEA Corrects the O-DSMT Schedule I Order to Cover Isomers, Esters, Ethers, and Salts. Retroactive to August 12.

DEA issued a correcting amendment to the temporary scheduling order that placed O-desmethyltramadol (O-DSMT) in Schedule I on August 12, 2026, effective October 9, 2026 (91 FR 64617, Docket DEA-1641). The agency stated it had "inadvertently omitted" the standard scope language. Section 1308.11(h)(88) now reads to cover O-desmethyltramadol and "its isomers, esters, ethers, salts, and salts of isomers, esters and ethers." The correction applies retroactively to August 12, 2026, and the order runs through August 12, 2028.

O-DSMT is the primary active mu-agonist metabolite of tramadol. Patients on therapeutic tramadol will produce O-DSMT in urine. If your program's interpretive language or SOPs cite the August order verbatim for the controlled-substance definition, those documents now reference an incomplete text. The relevant citation for current enforcement scope is the corrected CFR entry at section 1308.11(h)(88), not the August 12 Federal Register text.

Effective: October 9, 2026; retroactive to August 12, 2026  ·  91 FR 64617

Drug Alcohol Depend  ·  Cohort Study  ·  September 2026

A Telemedicine Bridge Clinic Increased Buprenorphine Fills by 17 Points and Reduced ED Visits by 18 Percent.

Lynch MJ and colleagues linked Pennsylvania Medicaid claims to bridge-clinic data for 552 patients matched to 2,208 comparison patients receiving usual office-based care. In the month after the qualifying encounter, 91.3 percent of bridge-clinic patients filled a buprenorphine prescription, against 73.6 percent in the comparison group. The bridge clinic was associated with a 6.9 percent increase in proportion of days covered and an 18.2 percent relative reduction in any emergency department visit. Lower Medicaid spending was driven by inpatient costs. (Drug Alcohol Depend. 2026;288:113374.)

JAMA Network Open  ·  Cohort Study  ·  October 2026

Every Additional Month of MOUD Through the Postpartum Period Cuts Overdose and Death Risk. The Median Event Is Six Months Out.

Kim and colleagues linked Tennessee Medicaid claims to vital records for 9,360 pregnancies, counting unique dispensed days of buprenorphine or naltrexone from 90 days before delivery through 41 days after. The one-year postpartum risk of overdose or death was 1.58 percent. The median time to that event was 186 days, well past the end of the typical six-week postpartum window most programs treat as the danger zone. Longer medication duration tracked with lower risk, and the lowest hazard ratio sat at full coverage of the 132-day exposure window (adjusted HR 0.52 versus a single day; 95% CI 0.31 to 0.88). (JAMA Netw Open. 2026;9(10):e2637214.)

From Bill

"The youth cascade data this month is one of the more important things published in this space in a while, not because the numbers are surprising, but because they are finally precise. Thirty-one out of thirty-two. That is how many young people with a diagnosed opioid use disorder do not remain on medication for six months. Every one of those stages where we lose them is a decision point we made, collectively, about what the system looks like. The point is not to feel bad about the number. The point is to know exactly which stage in your own program has the worst dropout rate, and to stop accepting it as inevitable."

Dr. William Bundy Jr., PharmD  ·  ToxiPharm LLC

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