Advanced Management of Alcohol Withdrawal

Advanced Management of Alcohol Withdrawal

EP 02 🎙 Special Series: ASAM's 57th Annual Conference This episode is part of a special three-part series spotlighting key sessions from ASAM’s 57th Annual Conference.   In this episode of ASAM Practice Pearls, In this episode of ASAM Practice Pearls, Dr. Stephen Taylor is joined by Drs. Tessa Steel and Melissa Weimer to discuss highlights from their Annual Conference session, Advanced Management of Alcohol Withdrawal: Case-Based, Evidence-Informed Solutions. Together, they explore the challenges of managing severe and resistant alcohol withdrawal syndrome (AWS), effective assessment tools, escalation strategies, and care considerations for high-risk or medically complex patients. ----more---- Looking for this episode's transcript? Download it HERE [https://elearning.asam.org/files/a1c38776-829d-4fc3-8a74-dfdd697b9325?ref_id=23761] Get credit for listening! Claim your 0.5 CEs HERE [https://elearning.asam.org/products/asam-practice-pearls-advanced-management-of-alcohol-withdrawal/?referral=APP_Ep8] Have an idea for a future episode? Share it with us at education@asam.org [education@asam.org]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states.  Expert Melissa Weimer, DO, MCR, DFASAM Dr. Melissa Weimer is board-certified in Internal Medicine and Addiction Medicine, focusing on substance use disorders in hospital settings.  She is an Associate Professor of Medicine at Yale School of Medicine and currently the Medical Director of the Yale Addiction Medicine Consult Service (YAMCS) at Yale New Haven Hospital. Dr. Weimer has worked on local, state, and national levels to enhance access to evidence-based treatments for substance use disorders.  As an educator, she teaches healthcare students and professionals about substance use disorders and serves as the Associate Program Director of the Yale Addiction Medicine Fellowship program. She is also the Medical Director/Lead Trainer for the SAMHSA-funded Providers Clinical Support System-Medications for Alcohol Use Disorder. Expert Tessa Steel, MD, MPH Dr. Tessa Steel is an Assistant Professor, physician-scientist, and Pulmonary Critical Care Medicine doctor at Harborview Medical Center, a county safety-net hospital operated by the University of Washington in Seattle. She is board-certified in Internal Medicine, Pulmonary Medicine, and Critical Care Medicine. Her clinical and research interests include improving hospital-based treatments for alcohol withdrawal syndrome and using hospitalizations to help people with addiction launch their process of recovery.  📖 Show Segments * 00:05 - Introduction  * 01:39  - Prevalence and Risk * 02:54 - Assessment Tools and Common Pitfalls * 08:41 - Escalating Pharmacological Strategy * 17:02 - Intubation Decisions and ICU Considerations * 21:57 - Key Takeaways * 25:37 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways * Use the right tools to assess alcohol withdrawal: There are several tools that can be used to monitor alcohol withdrawal symptoms and severity, including CIWA-Ar, mMINDS, and RASS; however, it's important to note that CIWA-Ar is not appropriate for patients with altered mental status or inability to self-report. Instead, use mMINDS, RASS, or other objective tools. * Treating alcohol withdrawal is about preventing brain injury, not just controlling agitation: Each withdrawal episode progressively upregulates NMDA receptors and worsens the risk of future brain hyperexcitation through a process called “kindling”. Inadequately treated brain hyperexcitation leads to neuron cell death, resulting in permanent brain damage. Therefore, effective management of alcohol withdrawal presents an opportunity to limit and prevent brain injury. * Match your pharmacology to the physiology and know what each drug is actually doing: Benzodiazepines give you GABA agonism only. Phenobarbital addresses the GABA agonism and glutamate antagonism and is much longer acting, hitting both sides of the main imbalance in the brain caused by alcohol. Dexmedetomidine helps control autonomic instability related to norepinephrine signaling but won't prevent seizures. Ketamine can directly antagonize NMDA-driven hyperexcitation when GABA-directed therapy isn't enough. Propofol gives you titratable cortical suppression once a patient requires intubation. * Front-load benzodiazepines early and monitor closely: When using benzodiazepines for severe alcohol withdrawal, give enough of the medication up-front. Falling behind is very hard to recover from; do not give a dose and walk away for hours without re-evaluation. * Always broaden your differential diagnosis: Severe alcohol withdrawal rarely occurs in isolation. Comorbid illnesses, such as infection, sepsis, trauma, or hepatitis, amplify the neurobiologic stress response and can make withdrawal look refractory when the real driver is something else. * Intubation is a high-stakes decision in this population: Intubation is a trade-off. In complex patients, such as those with advanced liver disease, active infection, or malnutrition, mechanical ventilation risks include secondary ventilator-associated pneumonia and prolonged sedation due to impaired drug clearance. The decision to ventilate should be deliberate, but once made, it should utilize titratable continuous sedation to reliably quiet brain excitation. * Hospitalization is an opportunity for engagement: AWS stabilization is not alcohol use disorder (AUD) treatment, and getting a patient safely through withdrawal is necessary but not sufficient. Withdrawal management should be a bridge to longitudinal AUD care, including shared decision-making, addiction consultation, and medications for AUD. 🔗 Resources *  Advanced Management of Alcohol Withdrawal: Case-Based, Evidence-Informed Solutions Annual Conference Session: Register HERE [https://elearning.asam.org/products/advanced-management-of-alcohol-withdrawal-case-based-evidence-informed-solutions?packages%5B%5D=249456&in_package=249456&sort_by=package_order&form_type=in-package-filter&webinar_type=0&date%5Bstart%5D=&date%5Bend%5D=&keywords=alcohol+withdrawal&ref=package&ref_id=249456/?referral=APP_8_1] * Handouts from session: * Yale New Haven Health System Phenobarbital Guidance [https://annualconference.asam.org/includes/tracking/assetClickTracking.asp?lfp=Zk1TM1B2Y0FOWklZQk5ISUNvVVhKWHNWOElvNHhYK2tUVDNsYzFMbXU4SnNWRGp0bDRjNGZrRzhERjZVcUhTQWdTc0lrT3AxcnRMbDYvYkExcHlSdGFpcjNibU8vZlc5UmQvYnhCSUZsU1ZZMzZEU2d5bzZ4VHJqNS80MzZXZWVQM0R2VVg1NHVwMGxTN2txTFhkUkRaSDBMSVlNSnJzak1yVXNlbHg4Q3g5a250Z090VC9UM3E4NmtvVWh3bWd0RGRkMmpqdXVXb0dabFAxTUdQUFcrUT09] * Supplemental Content from Wolpaw et al, 2025 [https://annualconference.asam.org/includes/tracking/assetClickTracking.asp?lfp=Zk1TM1B2Y0FOWklZQk5ISUNvVVhKZmNlWUY1bjdIOTVHTVFRNEdQdzVha2w1a2tjTXUvSWZVZVlod1h5QTFKV2I2amZ6RVhxQ1crRTNST25QVm81RStaOVYwWXk0bE95QVdxekYyK2M4RlJ6bjUvUmlpM2R4djVQU2NhZ0lET2lwR3V0Z2x0VWtIU0R2SnJwZHp4VEgrQkhSckt6OHc2dEVURDN5RkxBbE02UDNpRnpoMFdVTWFwYkhNSGVYRFduSkNtUGpjclhRWTU1dk1LbEpOT3dPdz09] * PCSS MAUD Education [https://asam-my.sharepoint.com/personal/lwood_asam_org/Documents/Podcast%20-%20ASAM%20Practice%20Pearls/Finalized%20Episodes/Season%202/Ep%208_AC%20Ep%202_Advanced%20Management%20of%20Alcohol%20Withdrawal/%E2%80%A2PCSS-MAUD%20Education:%20Free,%20comprehensive%20training,%20guidance,%20resources,%20and%20mentoring%20on%20the%20prevention,%20diagnosis,%20and%20treatment%20of%20AUD.%E2%80%AF%20%20%20oAssessment%20and%20Management%20of%20Alcohol%20Withdrawal%20%E2%80%93%20Online%20Course%20%20oAlcohol%20Withdrawal%20Syndrome%20in%20the%20Emergency%20Department%20%E2%80%93%20Mini%20Video]: Free, comprehensive training, guidance, resources, and mentoringon the prevention, diagnosis, and treatment of AUD. * Assessment and Management of Alcohol Withdrawal – Online Course [https://learning.pcss-maud.org/products/assessment-and-management-of-alcohol-withdrawal] * Medication Matters: Selecting the Right MAUD and Optimizing Outpatient Medically Managed Withdrawal – Online Course [https://learning.pcss-maud.org/products/medication-matters-selecting-the-right-maud-and-optimizing-outpatient-medically-managed-withdrawal] * Who is at Risk of Alcohol Withdrawal? Management in Ambulatory Care – Online Course [https://learning.pcss-maud.org/products/who-is-at-risk-of-alcohol-withdrawal-management-in-ambulatory-care] * Medications for Alcohol Use Disorder: Considerations for Patients with Comorbid Conditions – Digital Resource [https://learning.pcss-maud.org/files/a134f12e-e890-4323-946c-01c595aa537f?ref_id=29210] * Outpatient Management of Alcohol Withdrawal – Digital Resource [https://learning.pcss-maud.org/files/9ce0599d-06b8-4961-9df4-a34f47cf203e] * Treatment of Severe and Complicated Alcohol Withdrawal Syndrome – Digital Resource [https://learning.pcss-maud.org/files/a1528636-5d27-4508-b86a-d43272e7f2e3] * Alcohol Withdrawal Syndrome in the Emergency Department – Mini Video [https://www.youtube.com/watch?v=5OzgzmmbJds&t=69s] * Hospital-wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal. [https://pubmed.ncbi.nlm.nih.gov/40853658/] Wolpaw BJ, Oren HO, Quinnan-Hostein et al. JAMA Netw Open. 2025;8(8):e2528694. doi:10.1001/jamanetworkopen.2025.28694 2025 * Phenobarbital for Alcohol Withdrawal Syndrome Dosing Guidelines [https://files-profile.medicine.yale.edu/documents/2bc157ba-221b-4ac9-92ca-73c3383c45ce] - Yale New Haven Health; 2020. Accessed April 28, 2026. PDF * The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management [https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline] - American Society of Addiction Medicine. J Addict Med. 2020;14(3S Suppl 1):1-72. doi:10.1097/ADM.0000000000000668 * CIWA-Ar [https://umem.org/files/uploads/1104212257_CIWA-Ar.pdf] – The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is a validated, 10-question tool used to objectify the severity of alcohol withdrawal. * mMINDS [https://www.mdcalc.com/calc/10599/modified-minnesota-detoxification-scale] - The Modified Minnesota Detoxification Scale (mMINDS) is a 9-item tool to objectively score symptoms for patients with alcohol withdrawal. * RASS [https://www.mnhospitals.org/wp-content/uploads/Portals/Documents/ptsafety/LEAPT%20Delirium/RASS%20Sedation%20Assessment%20Tool.pdf] - The Richmond Agitation-Sedation Scale (RASS) is a 10-point scale used to objectively assess agitation and sedation levels in patients who cannot communicate. 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! https://www.linkedin.com/company/american-society-of-addiction-medicine/posts/?feedView=allhttps://www.facebook.com/addictionmedicine/https://x.com/asamorg?mx=2https://www.instagram.com/asamorg/https://www.youtube.com/@asamengagement In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Artificial Intelligence and the Future of Addiction Medicine

EP 01 🎙 Special Series: ASAM's 57th Annual Conference This episode is part of a special three-part series spotlighting key sessions from ASAM’s 57th Annual Conference.   In this episode of ASAM Practice Pearls, Dr. Elizabeth Salisbury-Afshar is joined by Drs. Sara Polley and Daniel Kaufman to explore highlights from their Annual Conference session, Artificial Intelligence and the Future of Addiction Medicine. Together, they discuss how artificial intelligence is reshaping addiction medicine, including the many ways AI is already being used in clinical care. The conversation focuses on informed consent, maintaining clinical judgment, and ethical considerations. ----more---- Looking for this episode's transcript? Download it HERE [https://elearning.asam.org/files/a1ab10a8-6e6c-484b-8bb9-33039c5a1872?ref_id=23761] Get credit for listening! Claim your 0.5 CEs HERE [https://elearning.asam.org/products/asam-practice-pearls-artificial-intelligence-and-the-future-of-addiction-medicine/?referral=APP_Ep7] Have an idea for a future episode? Share it with us at education@asam.org [education@asam.org]. Host Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FACPM, DFASAM Dr. Elizabeth Salisbury-Afshar is a family medicine, public health and general preventive medicine, and addiction medicine physician. Her work focuses on expanding access to evidence-based addiction treatment and harm reduction services, and she has over 14 years of experience practicing in medically underserved settings. Dr. Salisbury-Afshar is a Professor at the University of Wisconsin-Madison where she works clinically on an inpatient addiction consult team and is the Medical Director of a low-barrier walk-in clinic for people who use substances. Dr. Salisbury-Afshar is the Vice Chair of ASAM’s Medical Education Council and the Vice Chair of the Conference Program Planning Committee. Expert Sara Polley, MD, FAPA, FASAM Dr. Polley is a triple board-certified psychiatrist in adult, child, and adolescent psychiatry and addiction medicine. She provides integrated psychiatric care for youth and families at Vantage Mental Health, a nonprofit clinic serving both Minnesota and Wisconsin. In addition to her clinical work, Dr. Polley is a national consultant, speaker, and educator with the University of Minnesota Medical School. She serves on Minnesota’s Cannabis Advisory Council and holds committee appointments with the American Society of Addiction Medicine (ASAM) and the American Association of Child and Adolescent Psychiatry (AACAP). Dr. Polley is a passionate advocate for outpatient trauma-informed, developmentally appropriate, and family-centered co-occurring care, drawing on both her clinical experience and personal story as the child of a parent lost to addiction.  Expert Daniel Kaufmann, PhD, LPC, LMHC Dr. Kaufmann is an Associate Professor at Grand Canyon University as well as the Director of Gaming Services at Kindbridge Behavioral Health. He is the author of The Gamer’s Journey (2024), a book focused on explaining the presence of video games in society as a form of mythological storytelling and how these characters and settings can be used therapeutically for every gamer to complete each phase of the hero’s journey in their own lives. Dr. Kaufmann is currently serving as the co-chair of the APA research task force on video game issues and is working on several nationwide training programs to help mental health professionals understand video games in innovative ways. Dr. Kaufmann's publications cover the areas of video games, personality theory, online education, and counselor development. He offers supervision to an international list of clinicians to help bridge the gap in learning about technological impact on society and specific insights related to effective treatment for clients experiencing games-related issues.  📖 Show Segments * 00:05 - Introduction  * 01:19 - Expert Introduction and Initial Start with AI  * 04:40 - The Landscape of AI in Addiction Care * 06:41 - AI Assists Clinicians Might Not Realize They Are Using * 08:13 - AI for Search Tools and Scribes * 09:29 - Informed Consent for AI Tools * 14:02 - Patient's Reception of AI in Care Conversations * 15:41 - AI for Progress Notes and Documentation * 19:49 - AI for Patient Advocacy Letters * 22:04  - Guidance for Adopting AI Tools * 25:35 - Advice for Early-Career Health Care Providers * 26:21 - Approaching AI with Curiosity * 29:00 - Words of Advice * 32:50 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways * AI is already embedded throughout addiction care: Clinicians are integrating AI into their daily practice, including ambient scribes, literature search tools, helping write progress notes, billing systems, and EMR-driven risk alerts. * Informed consent for AI use requires careful consideration: Clinicians should consider the risk to the patient and the potential impact if the tool were to fail to help determine the appropriate level of AI-informed consent. Consider the risks of the tool failing, the likelihood of catching errors, and whether the patient has the ability to opt out before deciding whether to notify, obtain consent, or determine if consent is even needed. * AI scribes can free up significant time: Using ambient scribes can allow clinicians to focus more on the patient and the therapeutic relationship and less on documentation; however, clinicians must still review all AI-generated content carefully, never treating it as a finished, accurate product. * AI should support, not replace, clinical judgment: AI can be used as a resource to aid clinical administrative work, but it is not a substitute for diagnosis, treatment planning, or medical decision-making. The clinician remains responsible for all care decisions. * Early-career clinicians face a unique risk: Relying on AI before developing foundational clinical skills could lead to long-term competency gaps. Instead, use AI-generated content as a learning tool to develop necessary skills rather than as a shortcut. * Data privacy and HIPAA compliance are non-negotiable: Before adopting any AI tool, clinicians must verify where patient data is sent, who has access, and whether it is protected from being fed into wider internet systems. * Approach AI with curiosity and keep an open mind: AI isn’t going away. Learn how to work with it to help enhance your clinical practice. Educate yourself and use your own judgment on what may or may not be relevant for your own practice. 🔗 Resources * Artificial Intelligence and the Future of Addiction Medicine Annual Conference Session: Register HERE [https://elearning.asam.org/products/artificial-intelligence-and-the-future-of-addiction-medicine?packages%5B%5D=249456&in_package=249456&sort_by=package_order&form_type=in-package-filter&webinar_type=0&date%5Bstart%5D=&date%5Bend%5D=&keywords=AI&ref=package&ref_id=249456/?referral=APP_7_1] * 2 in 3 physicians are using health AI-up 78% from 2023 [https://www.ama-assn.org/practice-management/digital-health/2-3-physicians-are-using-health-ai-78-2023] - Henry TA. American Medical Association. February 26, 2025. Accessed April 25, 2026 * 77% of Americans Embrace AI in Behavioral Health, but Only with Transparency and Strong Safeguards [https://www.globenewswire.com/news-release/2026/02/18/3240313/0/en/77-of-Americans-Embrace-AI-in-Behavioral-Health-But-Only-with-Transparency-and-Strong-Safeguards.html] - GlobeNewswire Qualifacts. February 18, 2026. Accessed April 25, 2026 * A Scoping Review of AI-Driven Digital Interventions in Mental Health Care: Mapping Applications Across Screening, Support, Monitoring, Prevention, and Clinical Education [https://pubmed.ncbi.nlm.nih.gov/40428041/] - Ni Y, Jia F. Healthcare (Basel). 2025;13(10):1205. Published 2025 May 21. doi:10.3390/healthcare13101205 * Clinician Experiences With Ambient Scribe Technology to Assist With Documentation Burden and Efficiency [https://pubmed.ncbi.nlm.nih.gov/39969880/] - Duggan MJ, Gervase J, Schoenbaum A, et al. JAMA Netw Open. 2025;8(2):e2460637. Published 2025 Feb 3. doi:10.1001/jamanetworkopen.2024.60637 * Commercial Products Using Generative Artificial Intelligence Include Ambient Scribes, Automated Documentation and Scheduling, Revenue Cycle Management, Patient Engagement and Education, and Prior Authorization Platforms [https://pubmed.ncbi.nlm.nih.gov/40419172/] - Kunze KN, Bepple J, Bedi A, Ramkumar PN, Pean CA. Arthroscopy. 2025;41(11):4950-4955. doi:10.1016/j.arthro.2025.05.021 * Ethical Considerations for Clinical Adoption of Ambient Digital Scribe Technology [https://pubmed.ncbi.nlm.nih.gov/41453133/] - Anderson TN, Mohan V, Gold JA. J Am Med Inform Assoc. 2026;33(3):770-775. doi:10.1093/jamia/ocaf227 * Ethical Obligations to Inform Patients About Use of AI Tools [https://pubmed.ncbi.nlm.nih.gov/40690211/] - Mello MM, Char D, Xu SH. JAMA. 2025;334(9):767-770. doi:10.1001/jama.2025.11417 * New Doc on the Block: Scoping Review of AI Systems Delivering Motivational Interviewing for Health Behavior Change [https://pubmed.ncbi.nlm.nih.gov/40957014/] - Karve Z, Calpey J, Machado C, Knecht M, Mejia MC. J Med Internet Res. 2025;27:e78417. Published 2025 Sep 16. doi:10.2196/78417 * Patient Attitudes Toward Ambient Artificial Intelligence Scribes in Clinical Care: Insights From a Cross-Sectional Study [https://pubmed.ncbi.nlm.nih.gov/41350107/] - Chandrasekaran R, Moustakas E. J Am Med Inform Assoc. 2026;33(2):263-272. doi:10.1093/jamia/ocaf218 * Role of the States in the Future of AI Regulation [https://pubmed.ncbi.nlm.nih.gov/40965873/] - Mello MM, Childs PB, Roberts JL. JAMA Health Forum. 2025;6(9):e255020. Published 2025 Sep 5. doi:10.1001/jamahealthforum.2025.5020 * Teen and Young Adult Perspectives on Generative AI: Patterns of Use, Excitements, and Concerns [https://digitalthriving.gse.harvard.edu/wp-content/uploads/2024/06/Teen-and-Young-Adult-Perspectives-on-Generative-AI.pdf] - Hopelab, Common Sense Media, Center for Digital Thriving at Harvard Graduate School of Education. Published 2024. Accessed February 2026 📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! https://www.linkedin.com/company/american-society-of-addiction-medicine/posts/?feedView=allhttps://www.facebook.com/addictionmedicine/https://x.com/asamorg?mx=2https://www.instagram.com/asamorg/https://www.youtube.com/@asamengagement In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Navigating Cannabis and Cannabinoid Use in Today’s Clinical Practice

In this episode of ASAM Practice Pearls, Drs. Stephen Taylor and Takeo Toyoshima address the misconception that cannabis is not addictive. They discuss how clinicians can better understand the cannabis products their patients are using, navigate the changing legal landscape, and assess for cannabis use disorder using the “Three Cs” framework. The conversation highlights treatment strategies like motivational interviewing and harm reduction, managing cannabis withdrawal, the risk of psychosis from high-potency products, and emerging pharmacotherapy options. Throughout the episode, they offer practical strategies for keeping patients engaged in care.   ----more---- Looking for this episode's transcript? Download it HERE [https://elearning.asam.org/files/a18aab67-52e9-442b-842d-b585a06d2165?ref_id=23761] Get credit for listening! Claim your 0.5 CEs HERE [https://elearning.asam.org/products/asam-practice-pearls-navigating-cannabis-and-cannabinoid-use-in-todays-clinical-practice/?referral=APP_Ep6] Have an idea for a future episode? Share it with us at education@asam.org [education@asam.org]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Takeo Toyoshima, MD Dr. Takeo Toyoshima is the interim program director for the UCSF Addiction Psychiatry Fellowship. He completed medical school at UCLA, then psychiatry residency, addiction psychiatry fellowship, and forensic psychiatry fellowship at UCSF. His main clinical duties are at the San Francisco VA Health Care System, both in the Addiction Recovery Treatment Services' outpatient and intensive outpatient programs and in the Veterans Justice Outreach Clinic, which treats patients who are criminal justice-involved. In these settings, Dr. Toyoshima supervises UCSF medical students, psychiatry residents, addiction psychiatry fellows, and forensic psychiatry fellows, in addition to other allied health profession trainees. He concurrently serves as the VA site director for the UCSF Psychiatry and the Law Program. Outside of UCSF, Dr. Toyoshima also works in clinical and forensic private practice and serves in various roles in organized medicine (American Psychiatric Association, Northern California Psychiatric Society, California Society of Addiction Medicine, American Academy of Addiction Psychiatry, etc.). His clinical interests are in the intersection of psychiatry, addiction, and forensic matters.  📖 Show Segments * 00:05 - Introduction  * 01:13 - How to Approach the Conversation with Patients  * 03:51 - Clarifying Terms and Product Use with Patients * 05:52 - Legal and Regional Differences * 08:45 - Addressing Patient’s Perceived Pros and Cons of Cannabis * 11:19 - Assessing for Cannabis Use Disorder * 13:53 - What if a Patient Doesn’t Want to Stop? * 15:49 - Approaching Drug Testing with Patients * 17:43 - Recommended Treatment Options * 20:02  - Cannabis Withdrawal Symptoms * 22:08 - Considerations for Adolescents * 23:21 - The Risk of Psychosis * 24:46 - Harm Reduction * 27:22 - Signs of Cannabis Toxicity  * 31:46 - Key Takeaways * 33:20 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways * Cannabis addiction is real and common: Around 10% of people who start using become addicted, and around 30% of current users meet criteria for cannabis use disorder (CUD).  * Ask about products, routes, and potency: Flower, concentrates, edibles, and vapes carry very different risk profiles. Higher potency can lead to faster tolerance and withdrawal.   * Work collaboratively with your patients: Let patients educate you about their use, be curious, and use motivational interviewing techniques in conversation.  * Use the three Cs to assess CUD: Screen for issues with Control, Consequences, and Cravings, then map findings to the DSM-5 criteria together with the patient.  * Recognize cannabis withdrawal: Withdrawal symptoms affect 20–50% of daily users and can include both psychiatric and physical symptoms, such as appetite changes, nausea and vomiting, mild tremors, temperature dysregulation, irritability, anxiety, and mood changes. Sometimes, what patients attribute to anxiety or poor appetite may actually be withdrawal.  * Psychosis is a serious risk: Studies show around a 40% conversion to a schizophrenia diagnosis after a cannabis-induced psychotic episode, especially with high-potency products.  * No FDA-approved medications exist: Gabapentin and N-Acetylcysteine (NAC) are off-label pharmacotherapy options that show evidence for treating CUD, but treating co-occurring psychiatric disorders is equally important.  * Harm reduction is a valid goal: Reducing potency, spacing out use, switching routes, and building in breaks are practical steps when a patient isn't ready for abstinence.  * Keep patients coming back: The therapeutic relationship is the most powerful tool, so focus on patient goals and follow-up.   * Know your legal landscape and testing limitations: Laws vary by state. Standard urine screens will not detect synthetic cannabinoids, and THC metabolites can persist for weeks.  🔗 Resources * ASAM’s 57th Annual Conference [https://annualconference.asam.org/]: Register HERE [https://the-asam-57th-annual-conference.events.asam.org/] * Focus Session: High Risk at Every Stage: Cannabis Exposure During Critical Periods of Development    * ASAM 2025 Review Course: Psychiatric Co-morbidities: Complexities of Diagnosis and Care: Register HERE [https://elearning.asam.org/products/cannabis-use-disorder-science-trends-and-clinical-implications-2025/?referral=APP_Ep6_1]   * ASAM 56th Annual Conference:  * Cannabinoids and Pregnancy: ASAM Members, Patients and the Public - A Vital Discourse/Debate: Register HERE [https://elearning.asam.org/products/cannabinoids-and-pregnancy-asam-members-patients-and-the-public-a-vital-discoursedebate/?referral=APP_Ep6_2]  * Anyone Can Treat!: Master Youth Cannabis Use Treatment for Your Practice Setting: Register HERE [https://elearning.asam.org/products/anyone-can-treat-master-youth-cannabis-use-treatment-for-your-practice-setting/?referral=APP_Ep6_3]  * A Simple Guide to Pot, THC and How Much is Too Much [https://www.latimes.com/projects/la-me-weed-101-thc-calculator/]: Ramos Barreda A, De Leon K, Urmas S. Los Angeles Times. April 20, 2018. Accessed March 24, 2026.   * Cannabis/Marijuana Use Disorder [https://www.yalemedicine.org/conditions/marijuana-use-disorder]: Yale Medicine. July 24, 2024. Accessed March 30, 2026.   * Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis [https://pubmed.ncbi.nlm.nih.gov/29179576/]: Starzer MSK, Nordentoft M, Hjorthøj C. Am J Psychiatry. 2018;175(4):343-350. doi:10.1176/appi.ajp.2017.17020223 * The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research [https://www.nationalacademies.org/publications/24625]: National Academies of Sciences, Engineering, and Medicine. 2017. Washington, DC: The National Academies Press. * Transition From Substance-Induced Psychosis to Schizophrenia Spectrum Disorder or Bipolar Disorder [https://pubmed.ncbi.nlm.nih.gov/37132221/]: Rognli EB, Heiberg IH, Jacobsen BK, Høye A, Bramness JG. Am J Psychiatry. 2023;180(6):437-444. doi:10.1176/appi.ajp.22010076 * Understanding Your Risk for Cannabis Use Disorder [https://www.cdc.gov/cannabis/health-effects/cannabis-use-disorder.html]: Centers for Disease Control and Prevention. December 5, 2024. Accessed March 30, 2026.  📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! https://www.linkedin.com/company/american-society-of-addiction-medicine/posts/?feedView=allhttps://www.facebook.com/addictionmedicine/https://x.com/asamorg?mx=2https://www.instagram.com/asamorg/https://www.youtube.com/@asamengagement In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Kratom and 7-OH: What Clinicians Need to Know

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts researchers Dr. Kirsten Smith and Katie Hill to explore the rapidly evolving landscape of kratom and 7-hydroxymitragynine (7-OH). They examine kratom’s complex pharmacology, review current research on kratom and 7-OH, discuss kratom’s addiction potential, withdrawal patterns, and the challenges of kratom in the clinical setting. The episode provides listeners with a basic understanding of kratom and 7-OH products, helping clinicians better understand where to begin when treating patients who use kratom and kratom-derived products. ----more---- Looking for this episode's transcript? Download it HERE [https://elearning.asam.org/files/a170fd3c-ead4-45b0-a36d-589fda4768c2?ref_id=23761] Get credit for listening! Claim your 0.5 CEs HERE [https://elearning.asam.org/products/asam-practice-pearls-kratom-and-7-oh-what-clinicians-need-to-know/?referral=APP_Ep5] Have an idea for a future episode? Share it with us at education@asam.org [education@asam.org]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Kirsten Smith, PhD, LMSW   Dr. Kirsten Smith is a leading expert on kratom, with over 90 peer-reviewed publications on kratom and related topics like kava and tianeptine. From 2023-2025, she was an Assistant Professor at Johns Hopkins University School of Medicine’s Department of Psychiatry. She joined Hopkins after earning her Master’s from the University of Kentucky, PhD from the University of Louisville, and completing a 4-year postdoctoral fellowship at the National Institute on Drug Abuse Intramural Research Program (NIDA IRP). At NIDA IRP, she completed her K99-funded project that involved a national ecological momentary assessment of daily kratom use and a controlled drug administration sub-study that investigated the acute effects of commercial kratom products. Her R00-funded study at Johns Hopkins examined kratom pharmacokinetics/pharmacodynamics of kratom and assessed spontaneous kratom withdrawal among chronic consumers. She also received an R01 to study the safety, tolerability, and abuse potential of kratom in healthy adults, which is ongoing. She has conducted surveys and qualitative research on kratom and 7-hydroxymitragynine (7-OH). Dr. Smith is currently transitioning from academia to clinical practice but consults on kratom regularly and welcomes opportunities for collaboration. Disclosure: There are no relevant financial relationships.  Expert Katherine Hill, MPH   Katherine (Katie) Hill is a PhD candidate in Epidemiology of Microbial Diseases at Yale School of Public Health. Her research interests include substance use and harm reduction. Her doctoral research employs mixed methods to evaluate the impact of emerging substances, such as xylazine and kratom, on people who use drugs.  Disclosure: There are no relevant financial relationships.  📖 Show Segments * 00:05 - Introduction  * 01:49 - Defining Kratom  * 04:42 - Consumers of Kratom * 05:48 - Is Kratom an Opioid * 07:29 - Differences Between Kratom and 7-OH * 11:39 - Addiction Potential * 16:50 - Toxicity, Acute Intoxication, and Toxidrome * 18:55 - 7-OH Withdrawal and Overdose * 24:16 -  Patient History and Assessment  * 26:25 - Practice Pearls for Clinicians * 30:48 - Patient Motivations and Harm Reduction * 33:03 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways * “Kratom” is often used as a broad term for kratom-derived products: Kratom can refer to powdered leaves, capsules, teas, concentrated extracts, or semi-synthetic 7-OH products, many of which may also contain caffeine, kava, CBD, or other additives. When a patient says they use "kratom," it provides little clinical clarity. Clinicians need to ask which product, form, and brand the patient is using to better understand their usage patterns.  * Understand the product your patient is using: Product composition, potency, and co-ingredients of kratom are variable. Clinicians need to gather information on formulation, dosing, frequency, route, motivations, and co-use to gain a clear history. Self-report gives far more insight than current toxicology assays.   * Kratom’s pharmacology is complex: Kratom can produce pain relief via the serotonin and opioid system. Effects from kratom also include increases in energy and mood elevation. Some kratom alkaloids and metabolites have atypical mu-opioid receptor activity as well as non-opioid activity, making kratom’s pharmacology complex. Kratom can lead to physical dependence symptoms when consumed regularly.  * 7-OH is different from natural kratom: 7-hydroxymitragynine is found only in trace amounts in kratom leaves, but exists in much higher levels in commercial semi-synthetic products. These formulations behave differently and have low bioavailability, making their clinical effects distinct.  * Mild to moderate dependence and withdrawal are possible: Daily, repeated kratom use commonly leads to tolerance and withdrawal symptoms such as restlessness, irritability, fatigue, and cravings. Severe withdrawal appears uncommon in current data, though more evidence is needed, especially for 7-OH products.   * People can develop a kratom use disorder: About 25% of people using kratom meet criteria for kratom use disorder based on modified DSM-5 Criteria, though most presentations appear to be mild to moderate.  * Standard drug testing has limitations: Urine assays detect mitragynine, but a positive result can't distinguish between kratom leaf products and 7-OH products containing residual mitragynine. 7-OH is unstable in blood and rapidly metabolized, making detection challenging. Rely on self-report and consider asking patients to bring in their products for better clarity.  * Understand motivations for use: Many people who use kratom and 7-OH are not seeking intoxication. They're trying to manage pain or mood, function at work, self-treat withdrawal, etc. Treatment planning should account for these functional goals and incorporate motivational interviewing and shared decision-making. * Help is needed to move the field forward: Researchers are behind front-line clinicians in understanding these substances. There is still a lot that is unknown about kratom and kratom-derived products. Clinicians are encouraged to publish case reports, develop internal protocols, describe withdrawal symptoms, and refine assessments to better guide emerging best practices.  🔗 Resources * ASAM’s 57th Annual Conference [https://annualconference.asam.org/] - Register HERE [https://the-asam-57th-annual-conference.events.asam.org/] * General Session: Understanding the Evolving Drug Landscape: From Epidemiology to Clinical Practice  * Focus Session: Beyond Kratom: Novel Products Containing 7-OH, Pseudo, MGM, and Kava  * Chapter 5: Kratom-related Physical Dependence and Addiction [https://www.sciencedirect.com/science/chapter/edited-volume/abs/pii/B9780443274121000055] - Smith KE, Singh D, Grundmann O. In: Kratom History, Science and Therapeutic Potential. Academic Press; 2026:59-78. https://doi.org/10.1016/B978-0-443-27412-1.00005-5   * Clinically Characterizing Adults Who Use Kava or Kratom: Substance Use Disorder Assessment Challenges for Increasingly Popular Botanical Products [https://pubmed.ncbi.nlm.nih.gov/41322679/] - Hill K, Boyer EW, Smith KE. Drug Alcohol Depend Rep. 2025;17:100394. Published 2025 Nov 9. doi:10.1016/j.dadr.2025.100394  * Controversies in Assessment, Diagnosis, and Treatment of Kratom Use Disorder [https://pmc.ncbi.nlm.nih.gov/articles/PMC11344726/] - Smith KE, Epstein DH, Weiss ST. Curr Psychiatry Rep. 2024 Sep;26(9):487-496. doi: 10.1007/s11920-024-01524-1. Epub 2024 Aug 13. PMID: 39134892; PMCID: PMC11344726 * The Rise of Novel, Semi-synthetic 7-hydroxymitragynine Products [https://onlinelibrary.wiley.com/doi/10.1111/add.16728] - Smith KE, Boyer EW, Grundmann O, McCurdy CR, Sharma A. Addiction. 2024;120(2):387-388. doi:10.1111/add.16728   * National Institute on Drug Abuse (NIDA): Kratom [https://nida.nih.gov/research-topics/kratom] - Learn more about kratom, ongoing research, and additional resources.   📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! https://www.linkedin.com/company/american-society-of-addiction-medicine/posts/?feedView=allhttps://www.facebook.com/addictionmedicine/https://x.com/asamorg?mx=2https://www.instagram.com/asamorg/https://www.youtube.com/@asamengagement In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Social Determinants of Health: Making an Impact in Addiction Care

In this episode of ASAM Practice Pearls, Drs. Stephen Taylor and Sharon Stancliff explore the role of social determinants of health (SDoH) in addiction care. They discuss the biopsychosocial model of addiction and emphasize the importance of understanding social factors such as housing, transportation, and economic stability when providing effective care. They highlight the need for clinicians to engage with patients in their environments, advocate for policy changes, and address racial disparities in addiction treatment, offering practical strategies clinicians can use to support patients facing social challenges.   ----more---- Looking for this episode's transcript? Download it HERE [https://elearning.asam.org/files/a1443da8-56cb-4ff3-8e67-94373f027bdc?ref_id=23761] Get credit for listening! Claim your 0.5 CEs HERE [https://elearning.asam.org/products/asam-practice-pearls-social-determinants-of-health-making-an-impact-in-addiction-care/?referral=APP_Ep4] Have an idea for a future episode? Share it with us at education@asam.org [education@asam.org]. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board-certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Sharon Stancliff, MD   Dr. Stancliff is Associate Medical Director for Harm Reduction in Health Care at the AIDS Institute, NYSDOH and sees patients at a shelter in New York City. Dr. Stancliff has been working with people who use drugs since 1990, including the provision of primary care, drug treatment, HIV care, and syringe access. She is currently focused on opioid overdose prevention through expanding access to naloxone and expanding access to buprenorphine in primary care and in less traditional settings, such as syringe exchange programs. Dr. Stancliff graduated from the School of Medicine at the University of California at Davis, did her Family Practice residency at the University of Arizona, and completed the AIDS Institute-sponsored Nicolas Rango HIV Clinical Scholars Program at Beth Israel Medical Center in New York City. She is board-certified in Family Medicine and in Addiction Medicine. She served on the Public Policy Committee of ASAM.  📖 Show Segments * 00:05 - Introduction  * 02:29 - The Role of SDoH in Addiction  * 06:00 - Prioritizing Competing Social Needs * 08:57 - The Clinician’s Role in Addressing SDoH * 12:11 - Making Your Voice Heard * 14:09 - The Impact of Race on Addiction Treatment * 16:38 - Tailoring Treatment to Social Context * 19:31 - Navigating Social Networks and Environmental Challenges * 22:30 - Key Takeaways * 24:50 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways * View addiction through a biopsychosocial lens: Addiction involves complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. It doesn’t develop solely from biological factors, making it essential to address SDoH during treatment.  * Prioritize patients’ social needs: Housing instability, poverty, transportation access, food insecurity, and other environmental factors significantly impact a patient’s ability to engage in treatment and are often overlooked.  * Focus on safety, stability, and patient goals: Abstinence-only approaches are outdated. Treatment should prioritize whether patients are safer, more stable, and more engaged in care, even if they're still using substances. Focusing on harm reduction and incremental progress promotes patient-centered care and improves engagement.  * Engage patients in the community and provide low-threshold care: Meet patients where they are, shelters, streets, and needle exchanges, to better understand their challenges and build trust with populations that might fear traditional healthcare settings. Offering low-threshold community care rather than requiring clinic visits reduces barriers to access and further supports relationship-building.  * Tailor treatment to social realities: Adjust prescription lengths, visit frequency, and monitoring based on each patient’s circumstances (e.g., shorter prescriptions if someone can't safely store medications in a shelter, longer prescriptions to reduce transportation barriers).   * Recognize how race and criminalization shape treatment access: The war on drugs disproportionately harms people of color, creating cycles of incarceration, overdose risk, and barriers to housing and employment.  * Address loneliness and isolation: Many patients on buprenorphine often lack social support. Helping them identify healthy networks and community spaces can reduce loneliness and support recovery.  * Advocate for system-level change: Clinicians should make their voices heard by engaging with legislators, health departments, and professional organizations like ASAM to help shape policies that support low-threshold, flexible, and equitable addiction treatment options.  🔗 Resources * ASAM’s DEI Online Education Series (FREE):   * Taking Action to Minimize Inequalities in Addiction Medicine [https://elearning.asam.org/products/taking-action-to-eliminate-inequities-in-addiction-medicine/?referral=APP_Ep4_1]  * Addressing Intersectionality within Addiction Medicine [https://elearning.asam.org/products/addressing-intersectionality-within-addiction-medicine/?referral=APP_Ep4_2]   * Health Disparities in Substance Use Disorder  [https://elearning.asam.org/products/health-disparities-in-substance-use-disorder-2/?referral=APP_Ep4_3]  * Setting the Stage: Racism in the History of Substance Use and Addiction [https://elearning.asam.org/products/setting-the-stage-racism-in-the-history-of-substance-use-and-addiction-2/?referral=APP_Ep4_4]   * Advancing Racial Justice and Health Equity In the Context of Addiction Medicine [https://www.asam.org/advocacy/public-policy-statements/justice]: ASAM’s public statement to recognize, understand, and counteract the adverse effects of America’s historical, pervasive, and continuing systemic racism, specifically with respect to addiction prevention, early intervention, diagnosis, treatment, and recovery.  * Structural Competency Working Group [https://structcomp.org/]: An organization founded in the San Francisco Bay Area in 2014 that develops and shares curricula, workshops, and resources to help healthcare professionals recognize and address the social and structural determinants of health.   * Structural Competency [https://structural-competency.com/]: provides training materials and resources designed to help healthcare professionals understand and address the social, political, and economic structures that shape health disparities, supporting the broader mission of the Structural Competency Working Group.  * One Doctor’s Experience Shows the Battle for the Future of Addiction Medicine [https://www.npr.org/sections/shots-health-news/2026/01/05/nx-s1-5660694/addiction-treatment-opioids-cocaine-abstinence]: Pattani A. NPR via Houston Public Media. January 5, 2026.   📢 Join the Discussion Share your thoughts using #ASAMPracticePearls — we’d love to hear from you! https://www.linkedin.com/company/american-society-of-addiction-medicine/posts/?feedView=allhttps://www.facebook.com/addictionmedicine/https://x.com/asamorg?mx=2https://www.instagram.com/asamorg/https://www.youtube.com/@asamengagement In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.