Residential substance use treatment programs deliver a wide range of evidence-based interventions addressing biological, psychological, and social dimensions of recovery. Despite this comprehensive approach, care across phases of treatment often becomes fragmented, limiting clinical coherence and obscuring residual risk of return to use at key transition points. This article introduces the Four Dimensions of Resilience, a whole-person organizing structure designed to integrate multidisciplinary care across intake, treatment planning, and discharge in residential substance use treatment. The model conceptualizes recovery capacity across four interacting domains: resilient biology, emotional tone, cognitive orientation, and interpersonal connection. Rather than proposing new interventions, the model functions as an organizing structure that integrates existing evidence-based practices into a unified clinical map, supporting interdisciplinary communication and continuity of care. Practical applications across the residential continuum-including assessment, treatment planning, and discharge evaluation-are described. By providing a shared language for whole-person recovery, this approach may help treatment programs enhance clinical coherence and improve identification of residual vulnerability to return to use.

Background: Substance use disorders are prevalent among employees, making workplaces important settings for prevention, treatment engagement, and long-term recovery. However, many organizations continue to rely on punitive responses that discourage disclosure, increase stigma, and contribute to costly employee turnover.Objective(s): Apply the Reina Trust and Betrayal Model as a practical framework for addressing substance use disorders in the workplace through supportive accountability, trust preservation, and recovery-oriented organizational practices.Methods: This commentary integrates the Reina Trust and Betrayal Model with federal recovery-ready workplace guidance and literature on workplace-supported recovery. The model's three domains (contractual, communication and competence trust) are examined pertaining to substance use-related workplace events, including disclosure, treatment leave, return-to-work transitions, and return to use. The framework is used to identify managerial behaviors that balance employee support with workplace safety and performance expectations.Results: Application of the Reina framework demonstrates how trust can be maintained through collaborative renegotiation of job expectations, confidential and respectful communication practices, and strategies that preserve professional identity during treatment and reintegration. The model further positions return to use as an opportunity for structured trust repair rather than moral failure, enabling organizations to address safety or performance concerns while maintaining dignity and continuity of employment.Conclusion: Aligning recovery-ready workplace practices with Reina trust behaviors offers a pragmatic, behaviorally grounded approach to responding to substance use disorders. A trust-based strategy may reduce stigma, improve retention, support workforce stability, and mitigate the financial and operational consequences of employee turnover while promoting humane and accountable responses to recovery.

Opioid use disorder remains a critical public health challenge, marked by high prevalence, overdose deaths, and substantial societal burden. Despite the availability of effective medications for OUD (MOUD), treatment utilization remains suboptimal, particularly among special populations. Contributing factors include altered pharmacokinetics, complex comorbidities, heightened safety concerns, stigma, and limited clinician expertise. This review comprehensively summarizes the latest evidence and guidelines to inform approaches to medications for opioid use disorder in special populations, including individuals with hepatic, renal, or cardiovascular disease; HIV/AIDS; peripartum or breastfeeding status; concurrent alcohol or benzodiazepine use; perioperative care needs; and adolescence. Across these populations, MOUD are associated with reduced morbidity and mortality and should not be withheld solely due to medical comorbidity, pregnancy, concurrent substance use, or perioperative care needs. Methadone is consistently associated with the highest treatment retention but requires careful dosing and monitoring in patients with hepatic, renal, and cardiovascular disease and in those receiving interacting medications, including antiretroviral therapy. Buprenorphine demonstrates a favorable safety profile across medically complex populations and fewer clinically significant drug-drug interactions. Extended-release naltrexone may be appropriate for select patients who can maintain opioid abstinence prior to induction, though its use is constrained by initiation barriers and limited population-specific data. Persistent access gaps, particularly among adolescents, highlight the need for tailored implementation strategies and further research. Consequently, recognizing the distinct needs and barriers of special populations with OUD is essential, and tailoring care to these considerations can enhance treatment outcomes.

Hospitalized patients with opioid use disorder present unique clinical challenges, including higher rates of patient-directed discharge (PDD), incomplete treatment courses, and frequent readmissions. To compare outcomes in hospitalized patient encounters involving OUD and bacteremia that were ordered medications for opioid use disorder versus high-dose opioid agonist therapy (HDOAT) alone. This single-center, retrospective study included 268 OUD patients, 383 encounters, and 303 cases of bacteremia admitted to Temple University Hospital from Jan 1, 2020 through Dec 31, 2022. Outcomes of interest included PDD, 7 and 30-day readmission, inpatient mortality, length of stay (LOS), one year mortality and antibiotic completion. Bacteremia is a serious illness and requires long term treatment, thus it is an optimal model for this work. Of 383 encounters, 234 involved MOUD, and 149 involved HDOAT alone. Among the HDOAT group, doses were up to 2,070 MMEs/day. MOUD included buprenorphine and methadone. HDOAT included non-MOUD full agonist such as oxycodone and/or hydromorphone. For case-level outcomes, MOUD was associated with higher antibiotic completion (35.0% vs 23.3%, OR 1.77, p < 0.05). For encounter-level outcomes, MOUD was associated with lower PDD rates (38.5% vs 69.8%, OR 0.27, p < 0.0001) and longer LOS (8d vs 3d), seven-days readmission and inpatient mortality rates were similar between groups. However, 30-day readmission rate was lower in the MOUD group (32.9% vs 43.0%, OR 0.65, p < 0.05). PDD, readmission and mortality were similar regardless of timing of MOUD initiation (<72 h vs > 72h) or severity of opioid dependence. Notably, 23% of HDOAT cases successfully completed antibiotics, often across multiple encounters. MOUD initiation was associated with lower PDD and higher antibiotic completion rates. Timing of MOUD initiation did not affect outcomes. HDOAT may serve as a second-line approach to support continuity of care in patients declining MOUD.

Some individuals use substances to cope with their post-traumatic stress disorder symptoms. The emotional, behavioral, and spiritual experience of both their post-traumatic stress disorder and substance use disorder is manifested in a sense of powerlessness, which is caused by the inability to stop using despite negative consequences related to continued use. Thus, powerlessness is a prominent factor in recovery from substance use disorder. The aims of the present theoretical article were to (a) present the consequences of the co-morbid post-traumatic stress disorder and substance use disorder that can lead to powerlessness, (b) discuss powerlessness as empowering in recovery from substance use disorder based on Alcoholic Anonymous and Narcotic Anonymous programs and post-traumatic growth theory, and (c) present a model of overcoming powerlessness in recovery from substance use disorder. The present conceptual model is based on the premise that powerlessness is multidimensional and manifested on three levels: behavioral, mental, and spiritual. Addressing powerlessness effectively requires relating to these aspects, which is in alignment with the broad view of change in personality, social, and spiritual aspects in the post-traumatic growth approach. This article contributes to the field by presenting the intrapersonal, interpersonal, and spiritual aspects associated with powerlessness and by addressing its multilevel nature in a meaningful way.

Opioid use disorder (OUD) is a major public health challenge with high overdose mortality and healthcare utilization. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiometabolic and neurobiological benefits, including modulation of reward pathways linked to addiction. Preclinical and early clinical data suggest GLP-1RAs may reduce substance-seeking behaviors, but realworld outcomes in OUD remain unclear. We conducted a retrospective cohort study using the TriNetX US Collaborative Network to identify adults aged ≥18 years diagnosed with OUD between January 1, 2016, and October 30, 2025. GLP-1RA exposure was defined as a prescription within 1 month up to the date of OUD diagnosis. Propensity score matching (1:1) balanced demographic and clinical covariates, including medication for opioid use disorder (MOUD) treatments. Primary outcomes were all-cause mortality and opioid overdose; secondary outcomes included inpatient admissions and emergency department (ED) visits over 6-month to 5-year intervals. Among 473,906 individuals with OUD, 8,737 (1.8%) received a GLP-1RA; after propensity score matching, 8,052 patients remained in each cohort with wellbalanced baseline characteristics (all standardized mean differences ≤0.10). GLP-1RA use was associated with lower 5-year all-cause mortality (4.9% vs 10.9%; HR 0.63, p < 0.001) and reduced overdose risk (3.0% vs 4.8%; HR 0.81, p = 0.01). In addition, GLP-1RA therapy was linked to fewer inpatient admissions (HR 0.73) and ED visits (HR 0.83), both with p < 0.001. These findings suggest that GLP-1RA use was associated with lower mortality, overdose risk, and healthcare utilization, supporting further investigation of GLP-1RAs as potential adjunctive therapies for OUD.

This systematic review evaluated whether CUD can be coherently reconceptualized as a disorder of motivational dysregulation by synthesizing clinical, neurocognitive, and treatment-related evidence published over the last 10 years. A systematic search was conducted in PubMed, Scopus, Embase, and CINAHL for studies published between January 2015 and January 2026, in accordance with PRISMA 2020 guidelines. Eligible studies included adults with CUD and examined motivational processes, decision-making, reward valuation, goal-directed behavior, or motivation-focused mechanisms of treatment. Quantitative, qualitative, and mixed-methods studies were included. Two independent reviewers conducted study selection, with disagreements resolved through consensus Risk of bias was assessed using standardized tools appropriate to study design, and findings were synthesized narratively. Convergent evidence indicated clinically salient motivational features such as persistent ambivalence, diminished intrinsic goal pursuit, and return to use driven by contextual and affective factors rather than consumption severity alone. Neurocognitive findings implicated alterations in reward prediction, effort-based decision-making, and executive control relevant to motivational regulation. Interventions explicitly targeting motivation demonstrated superior engagement and treatment outcomes compared with abstinence-centric or deterrence-based approaches. Overall, risk of bias was low in well-conducted randomized controlled trials, while observational and neurocognitive studies demonstrated moderate risk due to potential confounding and measurement variability. Case-series designs exhibited higher risk of bias. In conclusion the evidence from the past decade supports reframing CUD as a disorder of motivational dysregulation rather than consumption per se, with important implications for assessment, treatment design, and return to use prevention.

Stigmatizing language describing substance use behaviors in clinical documentation and in patient education materials can harm patients and their families. Recent literature has discouraged the use of stigmatizing language in treatment settings and medical documentation. However, large language models (LLMs) generate output using previously generated text, including sources such as electronic health records which may include stigmatizing language. While artificial intelligence (AI) developers continue to update and create LLM products, these developers might prioritize other issues over reducing stigmatizing language surrounding substance use disorders. These diverging priorities make it possible that updated and new LLMs might not eliminate the problem of stigmatizing language in LLM output, even as researchers explore methods to reduce the impact of stigmatizing language in AI models. The potential for LLM output to include stigmatizing language warrants caution on the part of clinicians as AI developers release products intended to facilitate clinical documentation. This article identifies stigmatizing language regarding substance use disorders and explores the potential for LLM output to include stigmatizing language. The author also discusses several challenges that clinicians may face in preventing stigmatizing language from transferring from LLM output into medical records, including randomness inherent in LLM output, balancing appropriate versus inappropriate uses of potentially stigmatizing language, and the need for continued human review of medical documentation even in the face of potentially increased patient volumes. Finally, the author proposes that practicing clinicians be included in an ongoing, active process of iterative refinement of LLM output for clinical use to reduce the risk of perpetuating stigmatizing language regarding substance use disorders.

Alcohol may confound or complicate diagnosis of Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD). Though phosphatidylethanol (PETH) testing is widely available, its use among patients with MASLD has not been well established. This study set out to determine both the frequency of PETH testing and the rate of positive PETH tests among patients initially diagnosed with MASLD. We conducted a retrospective cohort study at a single institution of patients diagnosed with MASLD. Patient demographics, metabolic comorbidities, labs, and rate of PETH testing were collected. We compared characteristics of patients with and without PETH testing as well as those with positive results. LASSO regression was then used to identify predictive factors of a positive PETH test. We identified 10,208 patients who met the inclusion criteria; PETH testing was performed in only 700 patients (6.9%). Among those who underwent PETH testing, 275 patients (39.6%) had a positive PETH. Positive PETH results were associated with younger age, male sex, a lower BMI, the absence of diabetes, and elevated AST, ALT, and MCV values. However, using patient factors, the LASSO model demonstrated a poor ability to predict a positive PETH (AUC 0.64). Although PETH testing was only sent in a minority of patients diagnosed with MASLD, over a third were elevated. We found that patient and laboratory parameters were insufficient to predict potentially injurious alcohol use. These findings suggest that use of PETH testing may better inform care of patients with MASLD.