Addiction Medicine

More Native Americans have died of a drug overdose than members of any other racial or ethnic group in the US—which as a whole has seen drug overdose deaths triple since 1999. But little is known about the regional impact of opioids in tribal and urban American Indian/Alaska Native (AI/AN) communities, according to Indian Health Service (IHS) researchers from Portland, Oregon. They examined death records from the Washington State Center for Health Statistics to identify trends and disparities in drug, opioid-involved, and heroin-involved overdose deaths for AI/AN and non-Hispanic whites in Washington.

AI/AN and whites had similar overdose-related death rates during 1999 and 2001, but then the deaths began to multiply faster among Native Americans: Between 2013 and 2015, Native Americans were dying at nearly 3 times the rate of drug and opioid-related overdose. Heroin-related deaths were 4 times higher.

During 2013-2015, 184 AI/AN people died of a drug overdose in Washington; 126 from opioids. Most of the deaths were in urban communities (both Native American and white). Men were nearly twice as likely as women to die of overdose. Adults aged 25 to 54 years had the highest rates. Age-specific drug overdose mortality rates among AI/AN were almost twice those among whites.

The death rates are disturbing enough, but the researchers also found that death certificates that were not corrected for misclassification of AI/AN race underestimated the mortality rates among AI/AN by about 40%. For example, the uncorrected data showed 28.7 drug-overdose deaths in Washington. The corrected number was 40.9. In contrast, the uncorrected number for whites was 15.7, vs 15.1.

Even before correction for misclassification, AI/AN in Washington had higher drug-opioid-involved, and heroin-involved overdose mortality rates than did whites in Washington and AI/AN in the US.

The researchers note that misclassification of AI/AN in public health data can obscure the prevalence of disease and result in suppression of health statistics because of small numbers. That, in turn, can affect the ability of state and federal programs to direct resources needed for a “robust public health response to this epidemic.”

More Native Americans have died of a drug overdose than members of any other racial or ethnic group in the US—which as a whole has seen drug overdose deaths triple since 1999. But little is known about the regional impact of opioids in tribal and urban American Indian/Alaska Native (AI/AN) communities, according to Indian Health Service (IHS) researchers from Portland, Oregon. They examined death records from the Washington State Center for Health Statistics to identify trends and disparities in drug, opioid-involved, and heroin-involved overdose deaths for AI/AN and non-Hispanic whites in Washington.

AI/AN and whites had similar overdose-related death rates during 1999 and 2001, but then the deaths began to multiply faster among Native Americans: Between 2013 and 2015, Native Americans were dying at nearly 3 times the rate of drug and opioid-related overdose. Heroin-related deaths were 4 times higher.

During 2013-2015, 184 AI/AN people died of a drug overdose in Washington; 126 from opioids. Most of the deaths were in urban communities (both Native American and white). Men were nearly twice as likely as women to die of overdose. Adults aged 25 to 54 years had the highest rates. Age-specific drug overdose mortality rates among AI/AN were almost twice those among whites.

The death rates are disturbing enough, but the researchers also found that death certificates that were not corrected for misclassification of AI/AN race underestimated the mortality rates among AI/AN by about 40%. For example, the uncorrected data showed 28.7 drug-overdose deaths in Washington. The corrected number was 40.9. In contrast, the uncorrected number for whites was 15.7, vs 15.1.

Even before correction for misclassification, AI/AN in Washington had higher drug-opioid-involved, and heroin-involved overdose mortality rates than did whites in Washington and AI/AN in the US.

The researchers note that misclassification of AI/AN in public health data can obscure the prevalence of disease and result in suppression of health statistics because of small numbers. That, in turn, can affect the ability of state and federal programs to direct resources needed for a “robust public health response to this epidemic.”

More Native Americans have died of a drug overdose than members of any other racial or ethnic group in the US—which as a whole has seen drug overdose deaths triple since 1999. But little is known about the regional impact of opioids in tribal and urban American Indian/Alaska Native (AI/AN) communities, according to Indian Health Service (IHS) researchers from Portland, Oregon. They examined death records from the Washington State Center for Health Statistics to identify trends and disparities in drug, opioid-involved, and heroin-involved overdose deaths for AI/AN and non-Hispanic whites in Washington.

AI/AN and whites had similar overdose-related death rates during 1999 and 2001, but then the deaths began to multiply faster among Native Americans: Between 2013 and 2015, Native Americans were dying at nearly 3 times the rate of drug and opioid-related overdose. Heroin-related deaths were 4 times higher.

During 2013-2015, 184 AI/AN people died of a drug overdose in Washington; 126 from opioids. Most of the deaths were in urban communities (both Native American and white). Men were nearly twice as likely as women to die of overdose. Adults aged 25 to 54 years had the highest rates. Age-specific drug overdose mortality rates among AI/AN were almost twice those among whites.

The death rates are disturbing enough, but the researchers also found that death certificates that were not corrected for misclassification of AI/AN race underestimated the mortality rates among AI/AN by about 40%. For example, the uncorrected data showed 28.7 drug-overdose deaths in Washington. The corrected number was 40.9. In contrast, the uncorrected number for whites was 15.7, vs 15.1.

Even before correction for misclassification, AI/AN in Washington had higher drug-opioid-involved, and heroin-involved overdose mortality rates than did whites in Washington and AI/AN in the US.

The researchers note that misclassification of AI/AN in public health data can obscure the prevalence of disease and result in suppression of health statistics because of small numbers. That, in turn, can affect the ability of state and federal programs to direct resources needed for a “robust public health response to this epidemic.”

In 2016, news reports warned the public of an opioid epidemic gripping the nation.

Karen Mower/iStockphoto

But Madeline Vaughn, then a lead clinical intake coordinator at the Houston-based addiction treatment organization Council on Recovery, sensed something different was going on with the patients she checked in from the street.

Their behavior, marked by twitchy suspicion, a poor memory, and the feeling that someone was following them, signaled that the people coming through the center’s doors were increasingly hooked on a different drug: methamphetamine.

“When you’re in the boots on the ground,” Ms. Vaughn said, “what you see may surprise you, because it’s not in the headlines.”

In the time since, it’s become increasingly clear that, even as the opioid epidemic continues, the toll of methamphetamine use, also known as meth or crystal meth, is on the rise, too.

The rate of overdose deaths involving the stimulant more than tripled from 2011 to 2016, the Centers for Disease Control and Prevention reported.

But unlike the opioid epidemic – for which medications exist to help combat addiction – medical providers have few such tools to help methamphetamine users survive and recover. A drug such as naloxone, which can reverse an opioid overdose, does not exist for meth. And there are no drugs approved by the Food and Drug Administration that can treat a meth addiction.

“We’re realizing that we don’t have everything we might wish we had to address these different kinds of drugs,” said Margaret Jarvis, MD, a psychiatrist and distinguished fellow for the American Society of Addiction Medicine.

Meth revs up the human body, causing euphoria, elevated blood pressure, and energy that enables users to go for days without sleeping or eating. In some cases, long-term use alters the user’s brain and causes psychotic symptoms that can take up to one year after the person has stopped using it to dissipate.

Overdosing can trigger heart attacks, strokes, and seizures, which can make pinpointing the drug’s involvement difficult.

Meth users also tend to abuse other substances, which complicates first responders’ efforts to treat a patient in the event of an overdose, said David Persse, MD, EMS physician director for Houston. With multiple drugs in a patient’s system, overdose symptoms may not neatly fit under the description for one substance.

“If we had five or six miracle drugs,” Dr. Persse said, to use immediately on the scene of the overdose, “it’s still gonna be difficult to know which one that patient needs.”

Research is underway to develop a medication that helps those with methamphetamine addiction overcome their condition. The National Institute on Drug Abuse Clinical Trials Network is testing a combination of naltrexone, a medication typically used to treat opioid and alcohol use disorders, and an antidepressant called bupropion.

And a team from the Universities of Kentucky and Arkansas created a molecule called lobeline that shows promise in blocking meth’s effects in the brain.

For now, though, existing treatments, such as the Matrix Model, a drug counseling technique, and contingency management, which offers patients incentives to stay away from drugs, are key options for what appears to be a meth resurgence, said Dr. Jarvis.

Illegal drugs never disappear from the street, she said. Their popularity waxes and wanes with demand. And as the demand for methamphetamine use increases, the gaps in treatment become more apparent.

Dr. Persse said he hasn’t seen a rise in the number of calls related to methamphetamine overdoses in his area. However, the death toll in Texas from meth now exceeds that of heroin.

Provisional death counts for 2017 showed methamphetamine claimed 813 lives in the Lone Star State. By comparison, 591 people died because of heroin.

The Drug Enforcement Administration reported that the price of meth is the lowest the agency has seen in years. It is increasingly available in the eastern region of the United States. Primary suppliers are Mexican drug cartels. And the meth on the streets is now more than 90% pure.

“The new methods [of making methamphetamine] have really altered the potency,” said Jane Maxwell, PhD, research professor at the University of Texas at Austin’s social work school. “So the meth we’re looking at today is much more potent than it was 10 years ago.”

For Ms. Vaughn, who works as an outpatient therapist and treatment coordinator, these variables are a regular part of her daily challenge. So until the research arms her with something new, her go-to strategy is to use the available tools to tackle her patients’ methamphetamine addiction in layers.

She starts with writing assignments, then coping skills until they are capable of unpacking their trauma. Addiction is rarely the sole demon patients wrestle with, Ms. Vaughn said.

“Substance use is often a symptom for what’s really going on with someone,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

In 2016, news reports warned the public of an opioid epidemic gripping the nation.

Karen Mower/iStockphoto

But Madeline Vaughn, then a lead clinical intake coordinator at the Houston-based addiction treatment organization Council on Recovery, sensed something different was going on with the patients she checked in from the street.

Their behavior, marked by twitchy suspicion, a poor memory, and the feeling that someone was following them, signaled that the people coming through the center’s doors were increasingly hooked on a different drug: methamphetamine.

“When you’re in the boots on the ground,” Ms. Vaughn said, “what you see may surprise you, because it’s not in the headlines.”

In the time since, it’s become increasingly clear that, even as the opioid epidemic continues, the toll of methamphetamine use, also known as meth or crystal meth, is on the rise, too.

The rate of overdose deaths involving the stimulant more than tripled from 2011 to 2016, the Centers for Disease Control and Prevention reported.

But unlike the opioid epidemic – for which medications exist to help combat addiction – medical providers have few such tools to help methamphetamine users survive and recover. A drug such as naloxone, which can reverse an opioid overdose, does not exist for meth. And there are no drugs approved by the Food and Drug Administration that can treat a meth addiction.

“We’re realizing that we don’t have everything we might wish we had to address these different kinds of drugs,” said Margaret Jarvis, MD, a psychiatrist and distinguished fellow for the American Society of Addiction Medicine.

Meth revs up the human body, causing euphoria, elevated blood pressure, and energy that enables users to go for days without sleeping or eating. In some cases, long-term use alters the user’s brain and causes psychotic symptoms that can take up to one year after the person has stopped using it to dissipate.

Overdosing can trigger heart attacks, strokes, and seizures, which can make pinpointing the drug’s involvement difficult.

Meth users also tend to abuse other substances, which complicates first responders’ efforts to treat a patient in the event of an overdose, said David Persse, MD, EMS physician director for Houston. With multiple drugs in a patient’s system, overdose symptoms may not neatly fit under the description for one substance.

“If we had five or six miracle drugs,” Dr. Persse said, to use immediately on the scene of the overdose, “it’s still gonna be difficult to know which one that patient needs.”

Research is underway to develop a medication that helps those with methamphetamine addiction overcome their condition. The National Institute on Drug Abuse Clinical Trials Network is testing a combination of naltrexone, a medication typically used to treat opioid and alcohol use disorders, and an antidepressant called bupropion.

And a team from the Universities of Kentucky and Arkansas created a molecule called lobeline that shows promise in blocking meth’s effects in the brain.

For now, though, existing treatments, such as the Matrix Model, a drug counseling technique, and contingency management, which offers patients incentives to stay away from drugs, are key options for what appears to be a meth resurgence, said Dr. Jarvis.

Illegal drugs never disappear from the street, she said. Their popularity waxes and wanes with demand. And as the demand for methamphetamine use increases, the gaps in treatment become more apparent.

Dr. Persse said he hasn’t seen a rise in the number of calls related to methamphetamine overdoses in his area. However, the death toll in Texas from meth now exceeds that of heroin.

Provisional death counts for 2017 showed methamphetamine claimed 813 lives in the Lone Star State. By comparison, 591 people died because of heroin.

The Drug Enforcement Administration reported that the price of meth is the lowest the agency has seen in years. It is increasingly available in the eastern region of the United States. Primary suppliers are Mexican drug cartels. And the meth on the streets is now more than 90% pure.

“The new methods [of making methamphetamine] have really altered the potency,” said Jane Maxwell, PhD, research professor at the University of Texas at Austin’s social work school. “So the meth we’re looking at today is much more potent than it was 10 years ago.”

For Ms. Vaughn, who works as an outpatient therapist and treatment coordinator, these variables are a regular part of her daily challenge. So until the research arms her with something new, her go-to strategy is to use the available tools to tackle her patients’ methamphetamine addiction in layers.

She starts with writing assignments, then coping skills until they are capable of unpacking their trauma. Addiction is rarely the sole demon patients wrestle with, Ms. Vaughn said.

“Substance use is often a symptom for what’s really going on with someone,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

In 2016, news reports warned the public of an opioid epidemic gripping the nation.

Karen Mower/iStockphoto

But Madeline Vaughn, then a lead clinical intake coordinator at the Houston-based addiction treatment organization Council on Recovery, sensed something different was going on with the patients she checked in from the street.

Their behavior, marked by twitchy suspicion, a poor memory, and the feeling that someone was following them, signaled that the people coming through the center’s doors were increasingly hooked on a different drug: methamphetamine.

“When you’re in the boots on the ground,” Ms. Vaughn said, “what you see may surprise you, because it’s not in the headlines.”

In the time since, it’s become increasingly clear that, even as the opioid epidemic continues, the toll of methamphetamine use, also known as meth or crystal meth, is on the rise, too.

The rate of overdose deaths involving the stimulant more than tripled from 2011 to 2016, the Centers for Disease Control and Prevention reported.

But unlike the opioid epidemic – for which medications exist to help combat addiction – medical providers have few such tools to help methamphetamine users survive and recover. A drug such as naloxone, which can reverse an opioid overdose, does not exist for meth. And there are no drugs approved by the Food and Drug Administration that can treat a meth addiction.

“We’re realizing that we don’t have everything we might wish we had to address these different kinds of drugs,” said Margaret Jarvis, MD, a psychiatrist and distinguished fellow for the American Society of Addiction Medicine.

Meth revs up the human body, causing euphoria, elevated blood pressure, and energy that enables users to go for days without sleeping or eating. In some cases, long-term use alters the user’s brain and causes psychotic symptoms that can take up to one year after the person has stopped using it to dissipate.

Overdosing can trigger heart attacks, strokes, and seizures, which can make pinpointing the drug’s involvement difficult.

Meth users also tend to abuse other substances, which complicates first responders’ efforts to treat a patient in the event of an overdose, said David Persse, MD, EMS physician director for Houston. With multiple drugs in a patient’s system, overdose symptoms may not neatly fit under the description for one substance.

“If we had five or six miracle drugs,” Dr. Persse said, to use immediately on the scene of the overdose, “it’s still gonna be difficult to know which one that patient needs.”

Research is underway to develop a medication that helps those with methamphetamine addiction overcome their condition. The National Institute on Drug Abuse Clinical Trials Network is testing a combination of naltrexone, a medication typically used to treat opioid and alcohol use disorders, and an antidepressant called bupropion.

And a team from the Universities of Kentucky and Arkansas created a molecule called lobeline that shows promise in blocking meth’s effects in the brain.

For now, though, existing treatments, such as the Matrix Model, a drug counseling technique, and contingency management, which offers patients incentives to stay away from drugs, are key options for what appears to be a meth resurgence, said Dr. Jarvis.

Illegal drugs never disappear from the street, she said. Their popularity waxes and wanes with demand. And as the demand for methamphetamine use increases, the gaps in treatment become more apparent.

Dr. Persse said he hasn’t seen a rise in the number of calls related to methamphetamine overdoses in his area. However, the death toll in Texas from meth now exceeds that of heroin.

Provisional death counts for 2017 showed methamphetamine claimed 813 lives in the Lone Star State. By comparison, 591 people died because of heroin.

The Drug Enforcement Administration reported that the price of meth is the lowest the agency has seen in years. It is increasingly available in the eastern region of the United States. Primary suppliers are Mexican drug cartels. And the meth on the streets is now more than 90% pure.

“The new methods [of making methamphetamine] have really altered the potency,” said Jane Maxwell, PhD, research professor at the University of Texas at Austin’s social work school. “So the meth we’re looking at today is much more potent than it was 10 years ago.”

For Ms. Vaughn, who works as an outpatient therapist and treatment coordinator, these variables are a regular part of her daily challenge. So until the research arms her with something new, her go-to strategy is to use the available tools to tackle her patients’ methamphetamine addiction in layers.

She starts with writing assignments, then coping skills until they are capable of unpacking their trauma. Addiction is rarely the sole demon patients wrestle with, Ms. Vaughn said.

“Substance use is often a symptom for what’s really going on with someone,” she said.

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

Children who are exposed to valproate in utero were more likely to be diagnosed with ADHD. Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Children who are exposed to valproate in utero were more likely to be diagnosed with ADHD. Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

Children who are exposed to valproate in utero were more likely to be diagnosed with ADHD. Also today, one expert calls for better ways to preserve beta cell function in youth, synthetic opioids drive a spike in the number of fatal overdoses, and mothers may play a role in the link between depression in fathers and daughters.

Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
 

New federal statistics suggest that the opioid epidemic in the United States is evolving as physicians crack down on the use of prescription painkillers: Fatal drug overdose deaths rose by 12% from 2016 to 2017, boosted by a wave of fatalities linked to illicit synthetic opioids like fentanyl that are now linked to an estimated 60% of opioid-related deaths.

US DEA

“Overall, the overdose epidemic continues to worsen, and it has grown increasingly complex by coinvolvement of prescription and illicit drugs,” Lawrence Scholl, PhD, MPH, and his associates at the Centers for Disease Control & Prevention wrote in the Morbidity and Mortality Weekly Report.

The new statistics provide more evidence that 2017 marked “a sharp increase in what has characterized as the third wave of the opioid epidemic,” said drug and health policy researcher Stephen Crystal, PhD, of Rutgers University, New Brunswick, N.J., in an interview. He was referring to a wave that experts believe started in 2013 amid a spike in U.S. overdose deaths from fentanyl and other synthetic opioids.

The new report analyzes fatal drug overdose data from 2013 to 2017. According to the findings, the total number of those overdoses rose to 70,237 in 2017, up from 63,632 in 2016. The highest drug overdose death rates in 2017 were in West Virginia, followed by Ohio, Pennsylvania, and the District of Columbia.

Some statistics did not change much from 2016 to 2017: About two-thirds of the drug overdose deaths were linked to opioids in both years, and the death rate of cases linked to prescription drugs and heroin remained steady. (Death rates in the report were age adjusted.)

However, the percentage of fatal overdose cases linked to synthetic opioids grew 45% from 2016 to 2017. Overall, 60% of opioid-related fatal overdoses in 2017 involved synthetic opioids.

The report identifies increases in several areas from 2016 to 2017. Opioid-related drug overdose deaths among black people rose by 25%, and an analysis of data from 34 states and the District of Columbia found the highest increases in death rates in North Carolina (29%), Ohio (19%), and Maine (19%).

In regard to deaths linked to synthetic opioids specifically, the highest death rates in 2017 were in West Virginia (37 per 100,000), Ohio (32 per 100,000), and New Hampshire (30 per 100,000).

“Part of what we’re seeing in these increased numbers are individuals who have pain, can’t get prescribed opioids, and turn to street drugs,” Dr. Crystal said, adding that “abruptly cutting patients off is not good, and leaving patients with a lot of untreated pain is not good. If people are going to be discontinued [from opioids] or have their doses reduced, the taper needs to be done very slowly and carefully.”

Synthetic opioids were not the only drugs that are driving up fatal overdoses, as the death rates of cases linked to cocaine and psychostimulants (such as methamphetamine) jumped by more than a third in 2017.

“The most important thing these numbers are telling me is that it’s becoming more and more attractive to drug dealers to put fentanyl in the heroin, cocaine, and other drugs they sell,” Dr. Crystal said. “When that happens, dependence on street drugs becomes much more deadly. It’s almost impossible to get the dose right. Every time you shoot up, you’re taking a chance that you’ll overdose.”

The report had limitations, including the fact that details about drug use were missing from 12% (2016) and 15% (2017) of death certificates in fatal overdose cases. By state, the percentages of those death certificates that included drug information ranged from as little as 55% to 99%.

There’s some possible positive news: The report points to preliminary data from 2018 suggesting that the number of annual drug overdose deaths may be leveling off – although it says more analysis is needed to confirm the trend.

Dr. Crystal, however, is not celebrating. “I don’t see this as a good news story, really,” he said, adding that there’s “a little too much of people patting themselves on the back” because they’re proud of cutbacks in opioid prescriptions.

“This doesn’t have to do with the huge number of people who got started with opioids years ago” and are now at risk of using street drugs, he said. “We haven’t engaged that population at the rate we need to. And flattening out at 70,000 drug overdoses a year is not a good news story.”

Dr. Crystal reported no relevant disclosures.

SOURCE: Scholl L et al. MMWR. 2019 Jan 4;67(5152):1419-27.

New federal statistics suggest that the opioid epidemic in the United States is evolving as physicians crack down on the use of prescription painkillers: Fatal drug overdose deaths rose by 12% from 2016 to 2017, boosted by a wave of fatalities linked to illicit synthetic opioids like fentanyl that are now linked to an estimated 60% of opioid-related deaths.

US DEA

“Overall, the overdose epidemic continues to worsen, and it has grown increasingly complex by coinvolvement of prescription and illicit drugs,” Lawrence Scholl, PhD, MPH, and his associates at the Centers for Disease Control & Prevention wrote in the Morbidity and Mortality Weekly Report.

The new statistics provide more evidence that 2017 marked “a sharp increase in what has characterized as the third wave of the opioid epidemic,” said drug and health policy researcher Stephen Crystal, PhD, of Rutgers University, New Brunswick, N.J., in an interview. He was referring to a wave that experts believe started in 2013 amid a spike in U.S. overdose deaths from fentanyl and other synthetic opioids.

The new report analyzes fatal drug overdose data from 2013 to 2017. According to the findings, the total number of those overdoses rose to 70,237 in 2017, up from 63,632 in 2016. The highest drug overdose death rates in 2017 were in West Virginia, followed by Ohio, Pennsylvania, and the District of Columbia.

Some statistics did not change much from 2016 to 2017: About two-thirds of the drug overdose deaths were linked to opioids in both years, and the death rate of cases linked to prescription drugs and heroin remained steady. (Death rates in the report were age adjusted.)

However, the percentage of fatal overdose cases linked to synthetic opioids grew 45% from 2016 to 2017. Overall, 60% of opioid-related fatal overdoses in 2017 involved synthetic opioids.

The report identifies increases in several areas from 2016 to 2017. Opioid-related drug overdose deaths among black people rose by 25%, and an analysis of data from 34 states and the District of Columbia found the highest increases in death rates in North Carolina (29%), Ohio (19%), and Maine (19%).

In regard to deaths linked to synthetic opioids specifically, the highest death rates in 2017 were in West Virginia (37 per 100,000), Ohio (32 per 100,000), and New Hampshire (30 per 100,000).

“Part of what we’re seeing in these increased numbers are individuals who have pain, can’t get prescribed opioids, and turn to street drugs,” Dr. Crystal said, adding that “abruptly cutting patients off is not good, and leaving patients with a lot of untreated pain is not good. If people are going to be discontinued [from opioids] or have their doses reduced, the taper needs to be done very slowly and carefully.”

Synthetic opioids were not the only drugs that are driving up fatal overdoses, as the death rates of cases linked to cocaine and psychostimulants (such as methamphetamine) jumped by more than a third in 2017.

“The most important thing these numbers are telling me is that it’s becoming more and more attractive to drug dealers to put fentanyl in the heroin, cocaine, and other drugs they sell,” Dr. Crystal said. “When that happens, dependence on street drugs becomes much more deadly. It’s almost impossible to get the dose right. Every time you shoot up, you’re taking a chance that you’ll overdose.”

The report had limitations, including the fact that details about drug use were missing from 12% (2016) and 15% (2017) of death certificates in fatal overdose cases. By state, the percentages of those death certificates that included drug information ranged from as little as 55% to 99%.

There’s some possible positive news: The report points to preliminary data from 2018 suggesting that the number of annual drug overdose deaths may be leveling off – although it says more analysis is needed to confirm the trend.

Dr. Crystal, however, is not celebrating. “I don’t see this as a good news story, really,” he said, adding that there’s “a little too much of people patting themselves on the back” because they’re proud of cutbacks in opioid prescriptions.

“This doesn’t have to do with the huge number of people who got started with opioids years ago” and are now at risk of using street drugs, he said. “We haven’t engaged that population at the rate we need to. And flattening out at 70,000 drug overdoses a year is not a good news story.”

Dr. Crystal reported no relevant disclosures.

SOURCE: Scholl L et al. MMWR. 2019 Jan 4;67(5152):1419-27.

New federal statistics suggest that the opioid epidemic in the United States is evolving as physicians crack down on the use of prescription painkillers: Fatal drug overdose deaths rose by 12% from 2016 to 2017, boosted by a wave of fatalities linked to illicit synthetic opioids like fentanyl that are now linked to an estimated 60% of opioid-related deaths.

US DEA

“Overall, the overdose epidemic continues to worsen, and it has grown increasingly complex by coinvolvement of prescription and illicit drugs,” Lawrence Scholl, PhD, MPH, and his associates at the Centers for Disease Control & Prevention wrote in the Morbidity and Mortality Weekly Report.

The new statistics provide more evidence that 2017 marked “a sharp increase in what has characterized as the third wave of the opioid epidemic,” said drug and health policy researcher Stephen Crystal, PhD, of Rutgers University, New Brunswick, N.J., in an interview. He was referring to a wave that experts believe started in 2013 amid a spike in U.S. overdose deaths from fentanyl and other synthetic opioids.

The new report analyzes fatal drug overdose data from 2013 to 2017. According to the findings, the total number of those overdoses rose to 70,237 in 2017, up from 63,632 in 2016. The highest drug overdose death rates in 2017 were in West Virginia, followed by Ohio, Pennsylvania, and the District of Columbia.

Some statistics did not change much from 2016 to 2017: About two-thirds of the drug overdose deaths were linked to opioids in both years, and the death rate of cases linked to prescription drugs and heroin remained steady. (Death rates in the report were age adjusted.)

However, the percentage of fatal overdose cases linked to synthetic opioids grew 45% from 2016 to 2017. Overall, 60% of opioid-related fatal overdoses in 2017 involved synthetic opioids.

The report identifies increases in several areas from 2016 to 2017. Opioid-related drug overdose deaths among black people rose by 25%, and an analysis of data from 34 states and the District of Columbia found the highest increases in death rates in North Carolina (29%), Ohio (19%), and Maine (19%).

In regard to deaths linked to synthetic opioids specifically, the highest death rates in 2017 were in West Virginia (37 per 100,000), Ohio (32 per 100,000), and New Hampshire (30 per 100,000).

“Part of what we’re seeing in these increased numbers are individuals who have pain, can’t get prescribed opioids, and turn to street drugs,” Dr. Crystal said, adding that “abruptly cutting patients off is not good, and leaving patients with a lot of untreated pain is not good. If people are going to be discontinued [from opioids] or have their doses reduced, the taper needs to be done very slowly and carefully.”

Synthetic opioids were not the only drugs that are driving up fatal overdoses, as the death rates of cases linked to cocaine and psychostimulants (such as methamphetamine) jumped by more than a third in 2017.

“The most important thing these numbers are telling me is that it’s becoming more and more attractive to drug dealers to put fentanyl in the heroin, cocaine, and other drugs they sell,” Dr. Crystal said. “When that happens, dependence on street drugs becomes much more deadly. It’s almost impossible to get the dose right. Every time you shoot up, you’re taking a chance that you’ll overdose.”

The report had limitations, including the fact that details about drug use were missing from 12% (2016) and 15% (2017) of death certificates in fatal overdose cases. By state, the percentages of those death certificates that included drug information ranged from as little as 55% to 99%.

There’s some possible positive news: The report points to preliminary data from 2018 suggesting that the number of annual drug overdose deaths may be leveling off – although it says more analysis is needed to confirm the trend.

Dr. Crystal, however, is not celebrating. “I don’t see this as a good news story, really,” he said, adding that there’s “a little too much of people patting themselves on the back” because they’re proud of cutbacks in opioid prescriptions.

“This doesn’t have to do with the huge number of people who got started with opioids years ago” and are now at risk of using street drugs, he said. “We haven’t engaged that population at the rate we need to. And flattening out at 70,000 drug overdoses a year is not a good news story.”

Dr. Crystal reported no relevant disclosures.

SOURCE: Scholl L et al. MMWR. 2019 Jan 4;67(5152):1419-27.

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

 

 

CASE CONTINUED

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

 

 

CASE CONTINUED

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.¹ First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,² MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.³

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.⁴ First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.^4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.⁵ While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.⁵ Exercise Compassion towards the patient’s struggles and experiences,⁵ and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.⁵ These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”⁴ so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

Continue to: CASE...

 

 

CASE CONTINUED

You use the last 15 minutes of Mr. C’s visit to conduct MI and acknowledge his ambivalence to change. Mr. C reveals that his motivation for change centers on how he perceives himself as a disappointment to his daughter because of his continuous drug use. At the end of the encounter, Mr. C is in tears but has a renewed motivation to stop using heroin. He agrees to enter substance abuse treatment.

Death by drug overdose is the number one cause of death in Americans 50 years of age and younger.¹ In 2016, there were 63,632 drug overdose deaths in the United States² Opioids were involved in 42,249 of these deaths, which represents 66.4% of all drug overdose deaths.² From 2015 to 2016, the age-adjusted rate of overdose deaths increased significantly by 21.5% from 16.3 per 100,000 to 19.8 per 100,000.² This means that every day, more than 115 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare.

The gold standard treatment is medication-assisted treatment (MAT)—the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach.³ When it comes to MAT options for opioid use disorder (OUD), there are 3 medications, each with its own caveats.

Methadone is an opioid mu-receptor full agonist that prevents withdrawal but does not block other narcotics. It requires daily dosing as a liquid formulation that is dispensed only in regulated clinics.

Buprenorphine is a mu-receptor high affinity partial agonist/antagonist that blocks the majority of other narcotics while reducing withdrawal risk. It requires daily dosing as either a dissolving tablet or cheek film. Recently it has also become available as a 6-month implant as well as a 1-month subcutaneous injection. Buprenorphine is also available as a combined medication with naloxone; naloxone is an opioid antagonist.

Naltrexone is a mu-receptor antagonist that blocks the effects of most narcotics. It does not lead to dependence, and is administered daily as a pill or monthly as a deep IM injection of its extended-release formulation.

The first 2 medications are tightly regulated options that are not available in many areas of the United States. Naltrexone, when provided as a daily pill, has adherence issues. As with any illness, lack of adherence to treatment is problematic; in the case of patients with OUD, this includes a high risk of overdose and death.

The use of injectable extended-release naltrexone (XR-NTX) may be a way to address nonadherence and thus prevent relapse. One of the challenges limiting naltrexone’s applicability has been the length of time required for an “opioid washout” of the mu receptors prior to administering naltrexone, which is a mu blocker. The washout can take as long as 7 to 10 days. This interval is not feasible for patients receiving inpatient treatment, and patients receiving treatment as outpatients are vulnerable to relapse during this time. Recently, there have been several attempts to shorten this gap through various experimental protocols based on incremental doses of NTX to facilitate withdrawal while managing symptoms.

Continue to: When selecting appropriate candidates for NTX treatment...

When selecting appropriate candidates for NTX treatment, clinicians should consider individuals who are:

• not interested in or able to receive agonist maintenance treatment (ie, patients who do not have access to an appropriate clinic in their area, or who are restricted to agonist treatment by probation/parole)
• highly abstinence-oriented (eg, active in a 12-step program)
• in professions where agonists are controversial (eg, healthcare and airlines)
• detoxified and abstinent but at risk for relapse.

Individuals who have failed agonist treatment (eg, who experience cravings for opioids and use opioids while receiving it, or are nonadherent or diverting/misusing the medication), who have a less severe form of OUD (short history and low level of use), or who use sporadically are also optimal candidates for NTX. Aside from the relapse-vulnerable washout gap prior to induction, one of the concerns with antagonist treatments is treatment retention; anecdotal clinical reports suggest that individuals often discontinue antagonists in favor of agonists.

Several studies have investigated this by comparing XR-NTX with buprenorphine-naloxone (BUP-NX). Here we summarize 3 studies^4-6 to describe which patients might be optimal candidates for XR-NTX, its success in comparison with BUP-NX, and challenges in induction of NTX, with a focus on emerging protocols (Table).

1. Tanum l, Solli KK, Latif ZH, et al. Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197-1205.

This study aimed to determine whether XR-NTX was not inferior to BUP-NX in the treatment of OUD.

Study design

• N = 159, multicenter, randomized, 12-week outpatient study in Norway
• After detoxification, participants were randomized to receive BUP-NX, 4 to 24 mg/d, or XR-NTX, 380 mg/month.

Continue to: Outcomes

Outcomes

• Comparable treatment retention between groups
• Comparable opioid-negative urine drug screens (UDS)
• Significantly lower opioid use in the XR-NTX group.

Conclusion

• XR-NTX was as effective as BUP-NX in maintaining short-term abstinence from heroin and other illicit opioids, and thus should be considered as a treatment option for opioid-dependent individuals.

While this study showed similar efficacy for XR-NTX and BUP-NX, it is important to note that the randomization occurred after patients were detoxified. As a full opioid antagonist, XR-NTX can precipitate severe withdrawal, so patients need to be completely detoxified before starting XR-NTX, in contrast to BUP-NX, which patients can start even while still in mild withdrawal. Additional studies are needed in which individuals are randomized before detoxification, which would make it possible to measure the success of induction.

2. Lee JD, Nunes, EV, Novo P, et al. Compar­ative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018;391(10118):309-318.

This study evaluated XR-NTX vs BUP-NX among adults with OUD who were actively using heroin at baseline and were admitted to community detoxification and treatment programs. Although the study began on inpatient units, it aimed to replicate usual community outpatient conditions across a 24-week outpatient treatment phase of this open-label, comparative effectiveness trial. Researchers assessed the effects on relapse-free survival, opioid use rates, and overdose events.

Study design

• N = 570, multicenter, randomized, 24-week study in the United States
• Detoxification methods: no opioids (clonidine or adjunctive medications), 3- to 5-day methadone taper, and 3- to 14-day BUP taper
• Protocol requirement: opioid-negative UDS before XR-NTX induction
• XR-NTX induction success ranged from 50% at a short-methadone-taper unit to 95% at an extended-opioid-free inpatient program. Nearly all induction failures quickly relapsed
• More participants inducted on BUP-NX group than XR-NTX group (94% vs 72%, respectively).

Continue to: Outcomes

Outcomes (once successfully inducted to treatment [n = 474])

• Comparable relapse events
• Comparable opioid-negative urine drug screens and opioid-abstinent days
• Opioid craving initially less with XR-NTX.

Conclusion

• It was more difficult to initiate patients on XR-NTX than BUP-NX, which negatively affected overall relapse rates. However, once initiated, both medications were equally safe and effective. Future work should focus on facilitating induction to XR-NTX and on improving treatment retention for both medications.

Regarding induction on NTX, patients must be detoxified and opioid-free for at least 7 days. If this medication is given to patients who are physically dependent and/or have opioids in their system, NTX will displace opioids off the receptor and precipitate a severe withdrawal (rather than a slow and gradual spontaneous withdrawal).

Several studies have examined the severity of opioid withdrawal (using Self Opioid Withdrawal Scale scoring) of patients undergoing detoxification with symptomatic management (eg, clonidine, loperamide, etc.), agonist-managed (eg, with a BUP taper), and without any assistance. As expected, the latter yielded the highest scoring and most uncomfortable experiences. Using scores from the first 2 groups, a threshold of symptom tolerability was established where patients remained somewhat comfortable during the process. During detoxification from heroin, administering any dose of NTX during the first 48 to 72 hours after the last use placed patients in a withdrawal of a magnitude above the limit of tolerability. At 48 to 72 hours, however, a very low NTX dose (3 to 6 mg) was found to be well tolerated, and withdrawal symptoms were easily managed supportively to accelerate the detoxification process. Several studies have attempted to devise protocols based on these findings in order to facilitate rapid induction onto NTX. The following study offers encouragement:

Continue to: 3. Sullivan M, Bisaga A, Pavlicova M...

3. Sullivan M, Bisaga A, Pavlicova M, et al. Long-acting injectable naltrexone induction: a randomized trial of outpatient opioid detoxification with naltrexone versus buprenorphine. Am J Psychiatry. 2017;174:459-467.

Study design

• N = 150 adults with OUD, randomized to outpatient opioid detoxification
• Patients were randomized to BUP- or NTX-facilitated detoxification, followed by XR-NTX
• BUP detoxification group underwent a 7-day BUP taper followed by a opioid-free week
• NTX group received a 1-day BUP dose followed by 6 days of ascending doses of oral NTX, along with clonidine and other adjunctive medications.

Outcomes

• NTX-assisted detoxification was significantly more successful for XR-NTX induction (56.1% vs 32.7%).

Conclusion

• Compared with the BUP-assisted detoxification group, NTX-assisted detoxification appears to make it significantly more likely for patients to be successfully inducted to XR-NTX.

The evidence discussed here holds promise in addressing some of the major issues surrounding MAT. For suitable candidates, XR-NTX seems to be as efficacious an option as agonist (BUP) MAT, and its induction limitations could be overcome by using NTX-facilitated detoxification protocols.

Death by drug overdose is the number one cause of death in Americans 50 years of age and younger.¹ In 2016, there were 63,632 drug overdose deaths in the United States² Opioids were involved in 42,249 of these deaths, which represents 66.4% of all drug overdose deaths.² From 2015 to 2016, the age-adjusted rate of overdose deaths increased significantly by 21.5% from 16.3 per 100,000 to 19.8 per 100,000.² This means that every day, more than 115 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare.

The gold standard treatment is medication-assisted treatment (MAT)—the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach.³ When it comes to MAT options for opioid use disorder (OUD), there are 3 medications, each with its own caveats.

Methadone is an opioid mu-receptor full agonist that prevents withdrawal but does not block other narcotics. It requires daily dosing as a liquid formulation that is dispensed only in regulated clinics.

Buprenorphine is a mu-receptor high affinity partial agonist/antagonist that blocks the majority of other narcotics while reducing withdrawal risk. It requires daily dosing as either a dissolving tablet or cheek film. Recently it has also become available as a 6-month implant as well as a 1-month subcutaneous injection. Buprenorphine is also available as a combined medication with naloxone; naloxone is an opioid antagonist.

Naltrexone is a mu-receptor antagonist that blocks the effects of most narcotics. It does not lead to dependence, and is administered daily as a pill or monthly as a deep IM injection of its extended-release formulation.

The first 2 medications are tightly regulated options that are not available in many areas of the United States. Naltrexone, when provided as a daily pill, has adherence issues. As with any illness, lack of adherence to treatment is problematic; in the case of patients with OUD, this includes a high risk of overdose and death.

The use of injectable extended-release naltrexone (XR-NTX) may be a way to address nonadherence and thus prevent relapse. One of the challenges limiting naltrexone’s applicability has been the length of time required for an “opioid washout” of the mu receptors prior to administering naltrexone, which is a mu blocker. The washout can take as long as 7 to 10 days. This interval is not feasible for patients receiving inpatient treatment, and patients receiving treatment as outpatients are vulnerable to relapse during this time. Recently, there have been several attempts to shorten this gap through various experimental protocols based on incremental doses of NTX to facilitate withdrawal while managing symptoms.

Continue to: When selecting appropriate candidates for NTX treatment...

When selecting appropriate candidates for NTX treatment, clinicians should consider individuals who are:

• not interested in or able to receive agonist maintenance treatment (ie, patients who do not have access to an appropriate clinic in their area, or who are restricted to agonist treatment by probation/parole)
• highly abstinence-oriented (eg, active in a 12-step program)
• in professions where agonists are controversial (eg, healthcare and airlines)
• detoxified and abstinent but at risk for relapse.

Individuals who have failed agonist treatment (eg, who experience cravings for opioids and use opioids while receiving it, or are nonadherent or diverting/misusing the medication), who have a less severe form of OUD (short history and low level of use), or who use sporadically are also optimal candidates for NTX. Aside from the relapse-vulnerable washout gap prior to induction, one of the concerns with antagonist treatments is treatment retention; anecdotal clinical reports suggest that individuals often discontinue antagonists in favor of agonists.

Several studies have investigated this by comparing XR-NTX with buprenorphine-naloxone (BUP-NX). Here we summarize 3 studies^4-6 to describe which patients might be optimal candidates for XR-NTX, its success in comparison with BUP-NX, and challenges in induction of NTX, with a focus on emerging protocols (Table).

1. Tanum l, Solli KK, Latif ZH, et al. Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197-1205.

This study aimed to determine whether XR-NTX was not inferior to BUP-NX in the treatment of OUD.

Study design

• N = 159, multicenter, randomized, 12-week outpatient study in Norway
• After detoxification, participants were randomized to receive BUP-NX, 4 to 24 mg/d, or XR-NTX, 380 mg/month.

Continue to: Outcomes

Outcomes

• Comparable treatment retention between groups
• Comparable opioid-negative urine drug screens (UDS)
• Significantly lower opioid use in the XR-NTX group.

Conclusion

• XR-NTX was as effective as BUP-NX in maintaining short-term abstinence from heroin and other illicit opioids, and thus should be considered as a treatment option for opioid-dependent individuals.

While this study showed similar efficacy for XR-NTX and BUP-NX, it is important to note that the randomization occurred after patients were detoxified. As a full opioid antagonist, XR-NTX can precipitate severe withdrawal, so patients need to be completely detoxified before starting XR-NTX, in contrast to BUP-NX, which patients can start even while still in mild withdrawal. Additional studies are needed in which individuals are randomized before detoxification, which would make it possible to measure the success of induction.

2. Lee JD, Nunes, EV, Novo P, et al. Compar­ative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018;391(10118):309-318.

This study evaluated XR-NTX vs BUP-NX among adults with OUD who were actively using heroin at baseline and were admitted to community detoxification and treatment programs. Although the study began on inpatient units, it aimed to replicate usual community outpatient conditions across a 24-week outpatient treatment phase of this open-label, comparative effectiveness trial. Researchers assessed the effects on relapse-free survival, opioid use rates, and overdose events.

Study design

• N = 570, multicenter, randomized, 24-week study in the United States
• Detoxification methods: no opioids (clonidine or adjunctive medications), 3- to 5-day methadone taper, and 3- to 14-day BUP taper
• Protocol requirement: opioid-negative UDS before XR-NTX induction
• XR-NTX induction success ranged from 50% at a short-methadone-taper unit to 95% at an extended-opioid-free inpatient program. Nearly all induction failures quickly relapsed
• More participants inducted on BUP-NX group than XR-NTX group (94% vs 72%, respectively).

Continue to: Outcomes

Outcomes (once successfully inducted to treatment [n = 474])

• Comparable relapse events
• Comparable opioid-negative urine drug screens and opioid-abstinent days
• Opioid craving initially less with XR-NTX.

Conclusion

• It was more difficult to initiate patients on XR-NTX than BUP-NX, which negatively affected overall relapse rates. However, once initiated, both medications were equally safe and effective. Future work should focus on facilitating induction to XR-NTX and on improving treatment retention for both medications.

Regarding induction on NTX, patients must be detoxified and opioid-free for at least 7 days. If this medication is given to patients who are physically dependent and/or have opioids in their system, NTX will displace opioids off the receptor and precipitate a severe withdrawal (rather than a slow and gradual spontaneous withdrawal).

Several studies have examined the severity of opioid withdrawal (using Self Opioid Withdrawal Scale scoring) of patients undergoing detoxification with symptomatic management (eg, clonidine, loperamide, etc.), agonist-managed (eg, with a BUP taper), and without any assistance. As expected, the latter yielded the highest scoring and most uncomfortable experiences. Using scores from the first 2 groups, a threshold of symptom tolerability was established where patients remained somewhat comfortable during the process. During detoxification from heroin, administering any dose of NTX during the first 48 to 72 hours after the last use placed patients in a withdrawal of a magnitude above the limit of tolerability. At 48 to 72 hours, however, a very low NTX dose (3 to 6 mg) was found to be well tolerated, and withdrawal symptoms were easily managed supportively to accelerate the detoxification process. Several studies have attempted to devise protocols based on these findings in order to facilitate rapid induction onto NTX. The following study offers encouragement:

Continue to: 3. Sullivan M, Bisaga A, Pavlicova M...

3. Sullivan M, Bisaga A, Pavlicova M, et al. Long-acting injectable naltrexone induction: a randomized trial of outpatient opioid detoxification with naltrexone versus buprenorphine. Am J Psychiatry. 2017;174:459-467.

Study design

• N = 150 adults with OUD, randomized to outpatient opioid detoxification
• Patients were randomized to BUP- or NTX-facilitated detoxification, followed by XR-NTX
• BUP detoxification group underwent a 7-day BUP taper followed by a opioid-free week
• NTX group received a 1-day BUP dose followed by 6 days of ascending doses of oral NTX, along with clonidine and other adjunctive medications.

Outcomes

• NTX-assisted detoxification was significantly more successful for XR-NTX induction (56.1% vs 32.7%).

Conclusion

• Compared with the BUP-assisted detoxification group, NTX-assisted detoxification appears to make it significantly more likely for patients to be successfully inducted to XR-NTX.

The evidence discussed here holds promise in addressing some of the major issues surrounding MAT. For suitable candidates, XR-NTX seems to be as efficacious an option as agonist (BUP) MAT, and its induction limitations could be overcome by using NTX-facilitated detoxification protocols.

Death by drug overdose is the number one cause of death in Americans 50 years of age and younger.¹ In 2016, there were 63,632 drug overdose deaths in the United States² Opioids were involved in 42,249 of these deaths, which represents 66.4% of all drug overdose deaths.² From 2015 to 2016, the age-adjusted rate of overdose deaths increased significantly by 21.5% from 16.3 per 100,000 to 19.8 per 100,000.² This means that every day, more than 115 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare.

The gold standard treatment is medication-assisted treatment (MAT)—the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach.³ When it comes to MAT options for opioid use disorder (OUD), there are 3 medications, each with its own caveats.

Methadone is an opioid mu-receptor full agonist that prevents withdrawal but does not block other narcotics. It requires daily dosing as a liquid formulation that is dispensed only in regulated clinics.

Buprenorphine is a mu-receptor high affinity partial agonist/antagonist that blocks the majority of other narcotics while reducing withdrawal risk. It requires daily dosing as either a dissolving tablet or cheek film. Recently it has also become available as a 6-month implant as well as a 1-month subcutaneous injection. Buprenorphine is also available as a combined medication with naloxone; naloxone is an opioid antagonist.

Naltrexone is a mu-receptor antagonist that blocks the effects of most narcotics. It does not lead to dependence, and is administered daily as a pill or monthly as a deep IM injection of its extended-release formulation.

The first 2 medications are tightly regulated options that are not available in many areas of the United States. Naltrexone, when provided as a daily pill, has adherence issues. As with any illness, lack of adherence to treatment is problematic; in the case of patients with OUD, this includes a high risk of overdose and death.

The use of injectable extended-release naltrexone (XR-NTX) may be a way to address nonadherence and thus prevent relapse. One of the challenges limiting naltrexone’s applicability has been the length of time required for an “opioid washout” of the mu receptors prior to administering naltrexone, which is a mu blocker. The washout can take as long as 7 to 10 days. This interval is not feasible for patients receiving inpatient treatment, and patients receiving treatment as outpatients are vulnerable to relapse during this time. Recently, there have been several attempts to shorten this gap through various experimental protocols based on incremental doses of NTX to facilitate withdrawal while managing symptoms.

Continue to: When selecting appropriate candidates for NTX treatment...

When selecting appropriate candidates for NTX treatment, clinicians should consider individuals who are:

• not interested in or able to receive agonist maintenance treatment (ie, patients who do not have access to an appropriate clinic in their area, or who are restricted to agonist treatment by probation/parole)
• highly abstinence-oriented (eg, active in a 12-step program)
• in professions where agonists are controversial (eg, healthcare and airlines)
• detoxified and abstinent but at risk for relapse.

Individuals who have failed agonist treatment (eg, who experience cravings for opioids and use opioids while receiving it, or are nonadherent or diverting/misusing the medication), who have a less severe form of OUD (short history and low level of use), or who use sporadically are also optimal candidates for NTX. Aside from the relapse-vulnerable washout gap prior to induction, one of the concerns with antagonist treatments is treatment retention; anecdotal clinical reports suggest that individuals often discontinue antagonists in favor of agonists.

Several studies have investigated this by comparing XR-NTX with buprenorphine-naloxone (BUP-NX). Here we summarize 3 studies^4-6 to describe which patients might be optimal candidates for XR-NTX, its success in comparison with BUP-NX, and challenges in induction of NTX, with a focus on emerging protocols (Table).

1. Tanum l, Solli KK, Latif ZH, et al. Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197-1205.

This study aimed to determine whether XR-NTX was not inferior to BUP-NX in the treatment of OUD.

Study design

• N = 159, multicenter, randomized, 12-week outpatient study in Norway
• After detoxification, participants were randomized to receive BUP-NX, 4 to 24 mg/d, or XR-NTX, 380 mg/month.

Continue to: Outcomes

Outcomes

• Comparable treatment retention between groups
• Comparable opioid-negative urine drug screens (UDS)
• Significantly lower opioid use in the XR-NTX group.

Conclusion

• XR-NTX was as effective as BUP-NX in maintaining short-term abstinence from heroin and other illicit opioids, and thus should be considered as a treatment option for opioid-dependent individuals.

While this study showed similar efficacy for XR-NTX and BUP-NX, it is important to note that the randomization occurred after patients were detoxified. As a full opioid antagonist, XR-NTX can precipitate severe withdrawal, so patients need to be completely detoxified before starting XR-NTX, in contrast to BUP-NX, which patients can start even while still in mild withdrawal. Additional studies are needed in which individuals are randomized before detoxification, which would make it possible to measure the success of induction.

2. Lee JD, Nunes, EV, Novo P, et al. Compar­ative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018;391(10118):309-318.

This study evaluated XR-NTX vs BUP-NX among adults with OUD who were actively using heroin at baseline and were admitted to community detoxification and treatment programs. Although the study began on inpatient units, it aimed to replicate usual community outpatient conditions across a 24-week outpatient treatment phase of this open-label, comparative effectiveness trial. Researchers assessed the effects on relapse-free survival, opioid use rates, and overdose events.

Study design

• N = 570, multicenter, randomized, 24-week study in the United States
• Detoxification methods: no opioids (clonidine or adjunctive medications), 3- to 5-day methadone taper, and 3- to 14-day BUP taper
• Protocol requirement: opioid-negative UDS before XR-NTX induction
• XR-NTX induction success ranged from 50% at a short-methadone-taper unit to 95% at an extended-opioid-free inpatient program. Nearly all induction failures quickly relapsed
• More participants inducted on BUP-NX group than XR-NTX group (94% vs 72%, respectively).

Continue to: Outcomes

Outcomes (once successfully inducted to treatment [n = 474])

• Comparable relapse events
• Comparable opioid-negative urine drug screens and opioid-abstinent days
• Opioid craving initially less with XR-NTX.

Conclusion

• It was more difficult to initiate patients on XR-NTX than BUP-NX, which negatively affected overall relapse rates. However, once initiated, both medications were equally safe and effective. Future work should focus on facilitating induction to XR-NTX and on improving treatment retention for both medications.

Regarding induction on NTX, patients must be detoxified and opioid-free for at least 7 days. If this medication is given to patients who are physically dependent and/or have opioids in their system, NTX will displace opioids off the receptor and precipitate a severe withdrawal (rather than a slow and gradual spontaneous withdrawal).

Several studies have examined the severity of opioid withdrawal (using Self Opioid Withdrawal Scale scoring) of patients undergoing detoxification with symptomatic management (eg, clonidine, loperamide, etc.), agonist-managed (eg, with a BUP taper), and without any assistance. As expected, the latter yielded the highest scoring and most uncomfortable experiences. Using scores from the first 2 groups, a threshold of symptom tolerability was established where patients remained somewhat comfortable during the process. During detoxification from heroin, administering any dose of NTX during the first 48 to 72 hours after the last use placed patients in a withdrawal of a magnitude above the limit of tolerability. At 48 to 72 hours, however, a very low NTX dose (3 to 6 mg) was found to be well tolerated, and withdrawal symptoms were easily managed supportively to accelerate the detoxification process. Several studies have attempted to devise protocols based on these findings in order to facilitate rapid induction onto NTX. The following study offers encouragement:

Continue to: 3. Sullivan M, Bisaga A, Pavlicova M...

3. Sullivan M, Bisaga A, Pavlicova M, et al. Long-acting injectable naltrexone induction: a randomized trial of outpatient opioid detoxification with naltrexone versus buprenorphine. Am J Psychiatry. 2017;174:459-467.

Study design

• N = 150 adults with OUD, randomized to outpatient opioid detoxification
• Patients were randomized to BUP- or NTX-facilitated detoxification, followed by XR-NTX
• BUP detoxification group underwent a 7-day BUP taper followed by a opioid-free week
• NTX group received a 1-day BUP dose followed by 6 days of ascending doses of oral NTX, along with clonidine and other adjunctive medications.

Outcomes

• NTX-assisted detoxification was significantly more successful for XR-NTX induction (56.1% vs 32.7%).

Conclusion

• Compared with the BUP-assisted detoxification group, NTX-assisted detoxification appears to make it significantly more likely for patients to be successfully inducted to XR-NTX.

The evidence discussed here holds promise in addressing some of the major issues surrounding MAT. For suitable candidates, XR-NTX seems to be as efficacious an option as agonist (BUP) MAT, and its induction limitations could be overcome by using NTX-facilitated detoxification protocols.