Importance: Evidence regarding the organization of civilian health care systems in active war zones is limited, yet critical for maintaining services for vulnerable populations. Objective: To describe the operational challenges and adaptive strategies implemented by an opioid agonist therapy (OAT) clinic to ensure continuity of care for patients maintained on methadone and buprenorphine during a period of prolonged armed conflict. Design: A descriptive case study of clinical, logistical, and regulatory adaptations following the escalation of conflict in Israel beginning 7 October 2023, through the 12-day Israel-Iran war in June 2025. Setting: A hospital-based ambulatory methadone maintenance treatment (MMT) clinic in the Tel Aviv region. Participants: A vulnerable population of patients with opioid use disorder (OUD) receiving daily or supervised OAT. Exposure(s): National emergency conditions, including mass evacuations, fluctuating missile threats from multiple fronts (Gaza, Lebanon, Yemen), and direct regional strikes in 2024 and 2025. Main Outcome(s) and Measure(s): The primary focus was maintaining treatment continuity through rapid protocol modifications and expanded take-home dose (THD) regulations. Results: The conflict necessitated immediate departures from standard clinical protocols. Key adaptations included the rapid expansion of THD eligibility to mitigate the risks associated with travel to the clinic during active shelling and the reallocation of resources. Regulatory frameworks were iteratively revised as the security situation evolved, shifting from daily supervised dosing to flexible, safety-oriented dispensing models. Conclusions and Relevance: Findings suggest that during national emergencies, decentralizing OAT through expanded THD regulations is essential to prevent treatment interruption and relapse. These adaptive strategies offer a framework for health policy in other conflict-affected regions to protect high-risk populations.

As aging is associated with physiological changes, patients in methadone maintenance treatment (MMT) may require an adequate methadone dose adjustment. We aimed to study the relationship between aging and methadone dose and plasma level. Patients with two methadone plasma level results, above one year apart, were included. Methadone dose and plasma levels, as well as their changes over time, were studied by age group. 318 patients, 36.5

Background:A rapid increase in opioid prescriptions necessitated the implementation of a specific opioid maintenance treatment arm in the Methadone Maintenance Treatment clinic for opioid use disorder (OUD). Objective:To characterize patients referred to this arm, those who initiated treatment and their outcomes. Methods:Individuals referred between November/2019 and June/2025 were included. Patient characteristics, retention, and drug abstinence were studied. Results:Of 184 referrals, 54 (29.3%) were admitted. They had a higher female proportion (50% vs. 32.3%, p=0.03) and more years of education (13.1±3.4 vs. 11.2±3.8, p=0.008) than those not admitted, with no significant age difference (50.5±15.8 vs. 52.0±16.4, p=0.6). Of the 54 admitted patients, 5 were transferred to the "regular" OUD arm. Of the remaining 49, 18.4% were treated with methadone and 40 with oral buprenorphine (21 switched later to a once-monthly injectable formulation). Overall, 42.9% used fentanyl: 44.4% of those on methadone, 42.1% on buprenorphine, and 42.9% on the injectable formulation. Ninety (51.4%) stayed one year; of them, 88.9% stopped prescription opioids. Cumulative retention was longer among females (2.3y, 95% CI: 1.8-2.9) than males (1.2y, 95% CI: 0.8-1.6, p=0.046). Retention among those treated with injectable buprenorphine (2.4y, 95% CI: 1.8-3.0) or methadone (1.7y, 95% CI: 0.9-2.4) was comparable, and both were longer than with oral buprenorphine (0.7y, 95% CI: 0.4-1.0, p<0.001 and p=0.039, respectively). Conclusion:Positive treatment outcomes were observed in this specific population, particularly among those treated with methadone or injectable buprenorphine, but future follow-up and a larger sample are needed. Physicians' education is necessary to achieve more accurate referrals.

Despite all Health Maintenance Organizations in Israel having documented an increased use of prescription opioids, a decrease in admissions with positive opioid toxicology was observed in emergency departments (EDs). We hypothesized that following the fentanyl test introduction in 2023 in the largest acute care facility in Israel, opioid detection and naloxone usage would increase, and death rates would decrease. Between 2016 and June 2024, 20,337 ED-admitted individuals were screened for drugs via urine toxicology tests. Opioid trends, their characteristics, the administration of naloxone, and death rates were analyzed. The pre- and since fentanyl testing initiation periods were compared. The proportion of individuals screened via urine toxicology increased from 0.7

Background The opioid epidemic and evolving circumstances occurred over the last 30 years. We aimed to study substance use over 3 decades in a large methadone maintenance treatment (MMT) facility within a tertiary-referral medical center and compare characteristics of patients between 3 time points, 10 years apart. Methods The prevalence of substance use was determined monthly between 1993 and 2024 based on observed random urine tests. A comparison of characteristics of current patients in January 2004, 2014, and 2024 were analyzed. Results The proportion of females decreased from 27 % to 20 %, and the age of admission rose from 37 to 43, but with no difference in the age of opioid use onset. The proportion of ‘ever’ drug injected, hepatitis C and B slightly reduced, significantly so, if patients who were at more than one time point were excluded. Over the years, cocaine misuse increased, and benzodiazepines remained high with a slight reduction. The opioid misuse rate was low and stable, cannabis was low but somewhat elevated, and amphetamines were very low to the point that their monitoring was infrequently. Conclusions While the good news is that drug injection, and infectious diseases are reduced over time, the increase in cocaine and cannabis is worrying, as well as the trend of older age when entering MMT, even though the age of opioid onset does not change. These trends are discussed along with potential explanations.

BACKGROUND:Pathological gambling is prevalent among methadone maintenance treatment patients. We aimed to study their long-term retention and survival which have not yet been studied. METHODS:Between 2006 and 2014, 350 patients in an MMT clinic were assessed for lifetime probable pathological gambling (PG) using the South Oaks Gambling Screen questionnaire. Their retention in MMT and survival up to June/2024 were analyzed using the Kaplan-Meier and Cox model. Vital data were obtained from a national registry. RESULTS:PG was identified in 60(17.1 %) patients. They had a higher male proportion (83.3 % vs. 65.2 %, p = 0.006). They were older at MMT entry (42.2 ± 9.5 vs. 38.6 ± 9.6, p = 0.007), had longer duration of opioid use, and an earlier cannabis onset, but had comparable opioid onset (22.5 ± 6.8) and were similar in the proportion of urine screened positive substances at MMT admission. The PG had shorter cumulative retention since the first admission and until the latest admission (13.1 years, 95 %CI 11.1-15.2) than the non-PG (17.2 years, 95 % CI 15.9-18.4, p = 0.009), also when excluding deaths during MMT (p = 0.013). Survival since admission to MMT was shorter in PG (19.2y, 95 %CI 16.9-21.5 vs. 24.4y 95 %CI 23.2-25.5, p < 0.001); however, with no difference by age at death observed. CONCLUSIONS:The PG group is characterized as males who were admitted to MMT at an older age following longer opioid usage duration. The PG failed to adhere to MMT; they dropped out, had shorter survival, although they did not die younger. Additional follow-up and specific intervention to improve their outcome are recommended.

The combination of pregabalin and opioid usage is a known risk for fatalities. The pregabalin misuse rate among patients in methadone maintenance treatment (MMT) is reported to be high. However, pregabalin’s risk among MMT patients, specifically concerning methadone dose and plasma level, is not yet determined. We aimed to study retention, survival, and whether pregabalin misuse is related to methadone dose and plasma level in MMT patients. An observational study was conducted on 273 patients at the MMT clinic in Tel Aviv, Israel. Inclusion criteria required having urine drug-screening results for pregabalin when evaluated for methadone plasma levels. Methadone dose and plasma level, drug in urine, sociodemographic, and addiction variables were taken from patients’ records. Patients with positive urine for pregabalin (n = 50) were comparable to 223 negative patients tested in methadone dose (124.3 ± 30.7 vs. 117.1 ± 42.5, p = 0.3) but had higher methadone plasma levels (693.8 ± 327.6 vs. 572.3 ± 286.5 ng/ml, p = 0.009) and QTc intervals on ECG (422.8 ± 31.8 vs. 412.1 ± 29.8 ms, p = 0.03). Logistic regression model found pregabalin tested positive as more likely to test positive for benzodiazepine (OR = 9.1), methylphenidate (OR = 5.5), and fentanyl (OR = 5.9), and to have higher methadone plasma levels (OR = 1.002). Cumulative retention (p < 0.001) and survival (p = 0.007) since admission to MMT were both shorter in the pregabalin group. Patients who tested positive for pregabalin presented high methadone plasma levels, even though they were treated with normal or low methadone doses. This phenomenon highlights the importance of monitoring methadone levels, which is not a routine procedure, to reduce patients’ risk.

Although recreational cannabis is not yet legalized in Israel, the increase in cannabis prescriptions may lead to an increase in its availability and abuse. To evaluate temporal changes in the prevalence of cannabis-positive urine toxicology tests among individuals admitted to the emergency department (ED) in a large tertiary medical center in Israel. Between January/2016 and June/2024, all ED-admitted individuals who had urine toxicology tests (n = 20,022) were included. Screening with urine toxicology increased from 0.7

Immediately following Hamas’ 2023 assault on Israel, a high prevalence of anxiety was reported among patients with opioid use disorder receiving methadone maintenance treatment (MMT), who all received a take-home methadone dose (THD) due to the war. We aimed to evaluate anxiety’s prevalence and severity one year following the ongoing war and to evaluate patient satisfaction with the THD expansion program. MMT patients were evaluated for anxiety using the General Anxiety Disorder-7 questionnaire and for THD satisfaction with a questionnaire at two time points (October 2023 and October 2024). Severe anxiety was observed in those unemployed and using substances. On follow-up, anxiety scores were reduced. Ninety percent of patients supported THD expansion due to safety and autonomy. A reduction in anxiety scores likely reflects adaptation to the wartime conditions. Future investigation of hybrid care models and the relationship between substance use and anxiety is needed.

Background/Objectives: Approximately one in five individuals will experience major depressive disorder (MDD), and 30% exhibit resistance to standard antidepressant treatments, resulting in a diagnosis of treatment-resistant depression (TRD). Historically, opium was used effectively to treat depression; however, when other medications were introduced, its use was discontinued due to addiction and other hazards. Recently, kappa opioid receptor (KOR) antagonism has been proposed as a potential mechanism for treating TRD. The main research question is whether commonly used psychotropic medications possess KOR antagonist properties and whether this characteristic could contribute to their efficacy in TRD. Methods: We investigated the antinociceptive effects of many psychotropic medications and their interactions with the opioid system. Mice were tested with a hotplate or tail-flick after being injected with different doses of these agents. Results: The antidepressants mianserin and mirtazapine (separately) induced dose-dependent antinociception, each yielding a biphasic dose–response curve. Similarly, the antidepressant venlafaxine produced a potent effect and reboxetine produced a weak effect. The antipsychotics risperidone and amisulpride exhibited a dose-dependent antinociceptive effect. The sedative–hypnotic zolpidem induced a weak bi-phasic dose-dependent antinociceptive effect. All seven psychotropic medications elicited antinociception, which was reversed by the non-selective opiate antagonist naloxone and, separately, by the kappa-selective antagonist Nor-BNI. Conclusions: Clinical studies are mandatory to establish the potential efficacy of augmentation of the treatment with antidepressants with these drugs in persons with treatment-resistant depression and the optimal dosage of medications prescribed. We suggest a possible beneficial effect of antidepressants with kappa antagonistic properties.

Background:A war state followed the October 7th, 2003, Hamas vast attack on civilians and military in the southern part of Israel, requiring an immediate adaptation of the routine functioning of the methadone maintenance treatment (MMT) clinics - typically, through the expansion of the take-home dose (THD) policies. Aim:To evaluate the level of anxiety and its relation to patients' satisfaction regarding THD expansion one month post-attack. Methods:Of the 320 current patients in one MMT clinic, 297 (92.8%) were interviewed for anxiety (GAD-7) and rated whether the THD expansion benefited them (1 to 5). Substance in urine, sociodemographic, and addiction history details were taken. Results:Of the participants, 35% were found to have no anxiety, 22.2% with mild, 21.9% with moderate, and 20.9% had severe anxiety. Logistic regression for anxiety found cocaine in urine and not opioids in urine (Odds Ratio (OR) = 3.6), history of having experienced physical violence (OR = 1.8), and not working (OR = 2.1) as risk factors. THD expansion benefited (scored ≥ 4) 82.2% of the responders, and in logistic regression for severe anxiety, not satisfied with THD expansion (OR = 2.9), being Israeli born (OR = 2.1), and not working (OR = 2.5) were included. Substance use did not change pre- and post-Hamas attack. Conclusion:Most patients were satisfied with the THD expansion. However, severe anxiety levels characterized those who were not, emphasizing the need for anxiety monitoring to determine those patients. Additional intervention and augmenting these patients' frequency of visits to the clinic (instead of THD expansion) is recommended so they have further meetings with their therapist and reduce their anxiety.

The significant benefits of physical activity are well-documented in academic literature, with growing evidence highlighting its positive effects (among others) on memory and cognitive function. Exercise, particularly aerobic activities, has been shown to mitigate neuroinflammatory processes, promote neuronal regeneration, facilitate recovery from cerebral trauma, and reduce the risk of neurodegenerative diseases. Among neurological conditions, traumatic brain injury (TBI) is the most common in individuals under 50, with 80-90 % of cases categorized as mild traumatic brain injury (mTBI). This study investigates the impact of exercise on visual and spatial memory deficits in mice following mTBI. ICR mice were subjected to a seventeen-day treadmill training protocol initiated at four different time intervals post-mTBI (2, 7, 13, and 30 days). A battery of specific behavioral tests was used to assess anxiety-like behaviors, motor skills, and visual and spatial memory. Our results indicate that running positively affected mTBI in both novel object recognition (p < 0.001) and Y-maze (p < 0.001) regardless of the running protocol's initiation time, demonstrating that aerobic exercise significantly alleviates cognitive deficits associated with mTBI. Importantly, mTBI did not appear to impact motor abilities or anxiety-like behaviors based on the assessment paradigms utilized. In conclusion, aerobic exercise effectively enhances visual and spatial memory post-mTBI, with promising results observed even when the running protocol is initiated up to one-month post-injury.

Introduction: Fentanyl is not yet routinely monitored among methadone maintenance treatment (MMT) patients in Israel. We aimed 1. to evaluate urine fentanyl proportion changes over 3 years and characterize patients' characteristics 2. To study patients' self-report on fentanyl usage, and compare knowledge about fentanyl risk, before and following brief educational intervention. Methods: Fentanyl in the urine of all current MMT patients was tested every 3 months year between 2021 and 2023, and patients with positive urine fentanyl were characterized. Current patients were interviewed using a fentanyl knowledge questionnaire (effects, indications, and risks) before and following an explanation session. Results: Proportion of fentanyl ranged between 9.8 and 15.1%, and patients with urine positive for fentanyl (September 2023) were characterized as having positive urine for pregabalin, cocaine, and benzodiazepine (logistic regression). Of the current 260 patients (87% compliance), 78(30%) self-reported of fentanyl lifetime use ("Ever"), and 182 "never" use. The "Ever" group had higher Knowledge scores than the "Never", both groups improved following the explanatory session (repeated measure). The "Ever" group patients were found with urine positive for cannabis and benzodiazepine on admission to MMT, they were younger, did not manage to gain take-home dose privileges and had a higher fentanyl knowledge score (logistic regression). Conclusions: In the absence of routine fentanyl tests, a high knowledge score, shorter duration in MMT, benzodiazepine usage on admission, and current cannabis usage, may hint of the possibility of fentanyl abuse.

Context Immigrants from the former Union of Soviet Socialist Republics (USSR) are more prevalent in Methadone maintenance treatment (MMT) in Israel than their percentage in the general population. Aims To compare their characteristics and outcomes to those of Israeli-born and other immigrant patients. Methods Retention and survival since admission (June/1993–Dec/2022) until leaving treatment (for retention), or at the end of follow-up were analyzed. Vital data was taken from a national registry. Predictors were estimated using Kaplan–Meier and Cox regression models. Results The USSR patients (N = 262) compared with other immigrants (N = 132) and Israeli-born (N = 696) were more educated (≥ 12y) ( p < 0.001), admitted to MMT at a younger age ( p < 0.001), following a shorter duration of opioid usage ( p < 0.001). More of them ever injected drugs ( p < 0.001) and ever drank alcohol ( p < 0.001). One-year retention was comparable (77.2% vs. 75.6% and 72%, p = 0.2) as did opioid discontinuation in those who stayed ( p = 0.2). Former USSR patients had longer cumulative retention of their first admission ( p = 0.05) with comparable overall retention since first admission, and survival, although the age of death was younger. Specific origin within the former USSR found immigrants from the Russian Federation with the best outcome, and those from Ukraine as having high HIV seropositive and shorter retention. Conclusions Despite several characteristics known to be associated with poor outcomes, former USSR immigrants showed better adherence to MMT, reflected by their longer cumulative retention in their first admission, lower rate of readmissions, and a comparable survival and overall retention in treatment. An in depth study is needed in order to understand why they decease at a younger age.

Disturbances in emotion regulation among opioid users receiving methadone maintenance treatment (MMT) was reported in a few small studies. We aimed to evaluate the prevalence and characteristics of patients in MMT with impaired emotion regulation. We studied a cross-sectional sample of 121 patients by means of the Difficulties in Emotion Regulation Scale (DERS). Data on clinical, sociodemographic and addiction variables were reviewed, including results of random observed urine testing for opioids, alcohol, cocaine, cannabis, and benzodiazepine (BDZ). The prevalence of a high DERS score (> 90) was 39%. Characteristics associated with high DERS scores (logistic regression model) were benzodiazepine misuse and 20 years of opioid use before admission to MMT. Among the subscales, IMPULSE and STRATEGIES were independently related to substance use (logistic regression). Greater cocaine usage was also more prevalent only in univariate analyses. The DERS score correlated inversely with years of education among patients with negative urine test. The DERS subscale score for AWARENESS was lower in females than in males as among patients with suicide attempts or involvement in physical violence. Since the IMPULSE and STRATEGIES scores predict drug use, these aspects of emotional regulation should be targeted first in third-wave cognitive-behavioral intervention in MMT.

Background Patients in methadone maintenance treatment (MMT) may develop age-related medical problems. Objective: To compare hypertension prevalence and its risk factors between two MMT clinics, having similar treatment guidelines, but different characteristics, one from Tel Aviv (TA) and one from Las Vegas (LV). Methods Prevalence of hypertension (systolic >= 140 and or diastolic >= 90 mmHg BP) among all current 291 MMT patients in TA and 180 patients in LV were studied, including body mass index (BMI), drugs in urine, sociodemographic, and addiction history data. Results Hypertension prevalence was comparable in TA (35.4%) and LV (34.4%), however TA patients were older (55.9 +/- 9.5 vs. 45.5 +/- 13.3, p < 0.001), with fewer females (22 vs. 42.2%, p < 0.001), fewer obese (BMI >= 30) (24 vs. 40.9%, p < 0.001), higher cocaine (21 vs. 7.8%, p < 0.001), and lower cannabis (14.1 vs. 32.4%, p < 0.001) and amphetamines (0 vs. 33.5%) users. Logistic regression found higher BMI to characterize hypertension in both clinics, but in TA also negative urine cocaine, benzodiazepine, and opioids screen, while in LV older age (>= 50 y), male gender, and negative urine cannabis screen. Conclusions While TA was characterized with older patients, LV patients had a comparable hypertension rate, as obesity was more prevalent. No drug use was accompanied by higher BMI in TA and therefore associated with hypertension. Weight reduction, hypertension detection and treatment are recommended.

Background: The COVID-19 pandemic led to several restrictions, particularly lockdowns, that required the adaptation of the routine functioning of methadone maintenance treatment (MMT) clinics - typically through take-home dose (THD) expansion. We aimed to study whether methadone maintenance treatment patients' satisfaction changed following the second as compared to the first COVID-19 pandemic lockdown. Methods: A satisfaction questionnaire covering diverse aspects of COVID-19, which asked for respondents' level of agreement (1 to 5), was administered to a non-selective sample of patients personally (N=44) during August 2020, and anonymously (N=120) during one week in January 2022. Results: The level of patients' protective hygiene behaviour to prevent COVID-19 infection was higher in the second survey (4.3 +/- 0.9 vs 4.0 +/- 0.6, p=0.03), as was satisfaction with the clinic's adaptation to the pandemic (4.0 +/- 0.9 vs 3.5 +/- 0.5, p<0.001). Although patients scored higher on exposure to illicit substances, their actual urine test outcomes for illegal sub-stances did not change (2.1 +/- 1.3 vs. 1.4 +/- 0.8, p=0.002). Patients without regular THD had lower scores of protective hy-giene behaviour and satisfaction with the clinic's adaptation in both surveys. Conclusions: Patients' satisfaction and sense of safety following the clinic's adaptation to the pandemic were higher at the second evaluation. Despite the improvement in patients' satisfaction with the adjustments made during the prolonged emergency imposed by the COVID-19 pandemic, research should be dedicated to the increase in illicit substance use perceived by patients during this period, as this was not borne out by tested-for-drug abuse rates, which were comparable to pre-pandemic rates.

BACKGROUND The current prevalence of hypertension (HTN) and risk factors that characterize its occurrence during long-term methadone maintenance treatment (MMT) have not been established. METHODS HTN was defined if either systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg was detected twice (one week apart) among adult MMT patients. Recorded and current body mass index (BMI), BP, methadone dose and serum level, and drugs in urine were analyzed. Data on socioeconomic and addiction history characteristics were also retrieved. RESULTS HTN was detected in 103 (35.4%) of the 291 study patients (age range 26-81 years, 62 females). The HTN and non-HTN groups were comparable in sex ( P =0.3), age (56.6±9.6 vs. 55.3±9.7 years, P =0.3), and duration in MMT (13.0±9.1 vs. 12.5±8.6 years, P =0.7). Age correlated linearly with duration in MMT (R=0.3, P <0.001) and with systolic BP (R=0.27, P <0.001). Patients with HTN had higher BMI values than those without HTN (28.1±5.4 vs. 25.5±5.2, respectively, P <0.001) and fewer had positive urine test findings to any substance (35.7% vs. 50.5%, P =0.01). Comparison of first methadone serum, BP, and BMI levels 11.9±5.8 years earlier increased more for the HTN group, independent of methadone dose and serum levels that lowered significantly over time. Drug abuse and older age were not associated with increased BMI and BP. CONCLUSION Weight gain was associated with BP elevation and characterized patients who succeeded in drug abstinence during MMT. PERSPECTIVES Identifying HTN and offering treatment for this highly prevalent life-threatening condition among older patients in MMT is recommended. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Adelson Family Foundation ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Helsinki Committee (IRB) of the Tel Aviv Sourasky Medical Center. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes no

Abstract Context Opioid use disorder (OUD) poses significant public health problems that have increased dramatically, resulting in high rates of morbidity and mortality. Objectives To minimize the risk of an opioid epidemic in Israel and be prepared, we evaluated physicians’ objective knowledge, level of stigma, and approach to prescribing opioids, risk factors, and identification of patients with substance use disorder (SUD), as well as their knowledge about opioid maintenance treatment (OMT) for OUD. Methods Anonymous computerized questionnaires were distributed nationally to physicians by the Israel Medical Association. Knowledge, stigma, and approach were scored. Results Of only 249 responders, 58.6% prescribe opioids, 32.1% prescribe cannabis, and 18.5% daily encounter patients with SUD. Logistic regression found the high knowledge group had daily encounters with SUD (Odds Ratio (OR) = 3.5, 95% CI 1.7–7.1) and were familiar with OMT (OR = 10.1, 95% CI 3.5–29.0). The high stigma group was characterized by physicians who prescribe opioids (OR = 1.7, 95% CI 1.0–2.9), but who self-reported having limited knowledge regarding OMT (OR = 2, 95% CI 1.1–3.7). The high approach group was characterized by those who prescribe opioids (OR = 11.7, 95% CI 4.9–28), prescribe cannabis (OR = 2.1, 95% CI 1.0–4.3), self-report having limited knowledge regarding OMT (OR = 11.2, 95% CI 1.4–89) and self-report identifying SUD (OR = 32.5, 95% CI 4.1–260). Conclusion High stigma was most evident among physicians who prescribe opioids but, importantly, who had limited knowledge specifically regarding OMT. Gaps in knowledge and approach were observed. An educational intervention is highly recommended to reduce stigma and increase referrals of patients for OMT, the most effective treatment for opioid use disorder.