Category: From Newswise – Substance Abuse

EMBARGO LIFTS AUGUST 29, 11AM EST

Author: Alex Manini, MD, MS, Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai, Director of the Center for Research on Emerging Substances, Poisoning, Overdose, and New Discoveries

Journal: JAMA Open – Embargo lifts August 29, 2023, 11 am EST

Bottom Line: A subclass of opioid drugs called nitazenes are now emerging in the illicit opioid supply in the United States and are more potent than even fentanyl. These nitazenes add a layer of complexity to the dangers of illicit drug use, leading to a significantly increased rate of cardiac arrest in overdose cases and significantly higher doses of naloxone for in-hospital treatment when compared to fentanyl overdoses.

Why This Study Is Unique: This is the first human study to show the clinical effects of new potent opioids such as brorphine and nitazene class drugs.  

Why This Study Is Important: This study is the first to identify the impact of new illicit opioids, including adverse consequences from nitazenes, such as frequent cardiac arrest, and higher dosage of naloxone for treatment.  

How the Study Was Conducted: Researchers analyzed 2,298 patients admitted with opioid overdoses to emergency departments across the country between 2020 and 2022.

Study Results:  Overdoses from the more potent opioids needed on average 1.33 doses of naloxone in-hospital, compared to 0.36 average doses for fentanyl overdose.  In addition, 100 percent of overdoses on one nitazene drug (metonitazene) had a cardiac arrest. 

What This Means for Clinicians/Hospitals: Clinicians in the United States should be aware of new potent opioids in the illicit drug supply and be prepared for higher naloxone dosing requirements. 

Quotes:

“Given the alarmingly high cardiac arrest rate for nitazene overdose, this study should energize harm-reduction policies. And given the emergence of dangerous toxic drugs in the illicit opioid supply in the United States, future research should examine clinical outcomes from new potent opioids as the supply continues to evolve,” says Alex Manini, MD, MS, Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai.

About the Mount Sinai Health System

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time—discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it.

Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. Hospitals within the System are consistently ranked by Newsweek’s® “The World’s Best Smart Hospitals” and by U.S. News & World Report‘s® “Best Hospitals” and “Best Children’s Hospitals.” The Mount Sinai Hospital is on the U.S. News & World Report‘s® “Best Hospitals” Honor Roll for 2023-2024.

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BYLINE: Greg Bruno

Newswise — Pregnant and recently postpartum women who suffer with mental health disorders may be vulnerable to using cannabis to self-medicate, according to a Rutgers-led study.

In a nationally representative survey, Qiana L. Brown, an assistant professor at the Rutgers School of Social Work, examined the relationship between mental health disorders, cannabis use and cannabis use disorder (CUD) among pregnant and postpartum women in the US. The findings were published in the journal Drug and Alcohol Dependence.

“Before this study, we didn’t know much about the associations between cannabis use, CUD and specific mental health disorders, such as bipolar disorder or specific phobia, among pregnant and postpartum women in the US,” Brown said. 

“Most prior research grouped mental health disorders into general classes, such as any mood disorder or any anxiety disorder, without examining the relationship between specific types of mood and anxiety disorders and cannabis use and CUD during and after pregnancy. 

Despite public health messaging encouraging women to abstain from using cannabis during pregnancy and while breast feeding, the prevalence of cannabis use by women of reproductive age has been increasing. 

In a previous study by Brown and colleagues published in the Journal of the American Medical Association, the prevalence of past month cannabis use increased 62 percent among pregnant women and 47 percent among nonpregnant women of reproductive age from 2002 to 2014.

In studies using smaller sample sizes, “pregnant and postpartum women used cannabis to relieve stress, anxiety and cope with mental health symptoms, which may indicate that they are self-medicating mental health conditions,” the researchers noted. 

“However, little is known about the mental health correlates of cannabis use and CUD among pregnant and postpartum women at the national level.” Given that most states have legalized cannabis for medical or recreational use, Brown said it’s important to understand mental health correlates of cannabis use and CUD among this population at the national level.

To address this research gap, Brown and colleagues from Columbia University, Washington University in St. Louis and École Polytechnique Fédérale de Lausanne in Switzerland analyzed the responses of 1,316 women in a national survey focused on drug and alcohol use and associated physical and mental disabilities. The sample included 414 women who were pregnant at the time of the interview and 902 postpartum women (pregnant in the past year).

What they found was a clear association between general classes of mental health disorders, cannabis use and CUD. For instance, pregnant and postpartum women who had any mood, anxiety or posttraumatic stress disorders in the past year or any lifetime history of personality disorder had higher odds of cannabis use and higher odds of CUD in the past year than women without a history of a given mental health disorder.

However, when mental health disorders were disaggregated into specific types, some mental health disorders were associated with cannabis use, but not CUD and vice versa. For example, while persistent and major depressive disorders were associated with both past year cannabis use and CUD, bipolar disorder was only associated with past year cannabis use, and not CUD (after accounting for potential confounding factors).

Additionally, cannabis use and CUD didn’t share common correlates regarding anxiety disorders. Social anxiety and panic disorders were associated with increases in cannabis use, but not CUD, while specific phobia was associated with increases in CUD and not cannabis use.

Previous studies that have examined the relationship between mental health disorders, cannabis use and CUD among pregnant or postpartum women primarily focused on patient- samples, not women from the general US population, used smaller samples sizes or focused on a limited number of mental health disorders. 

In total, the researchers examined three general classes of mental health disorders and 12 specific types of mental health disorders and their relationship with cannabis use and CUD.

“This level of specificity and the generalizability of our results can help inform tailored treatment and population-level preventive interventions,” said Brown.

Newswise — August 24, 2023 – As use and misuse of alcohol, opioids, and psychostimulants continues to increase, anesthesiologists can become a more integral part of the care team managing patients with a Substance Use Disorder (SUD), according to a series of three articles published in the September issue of Anesthesia & Analgesia, the official journal of the International Anesthesia Research Society. The journal is published in the Lippincott portfolio by Wolters Kluwer.

The articles provide an overview of SUDs specific to the anesthesiologist and offer insights into pain management for opioid use disorder and exposure to psychostimulants. “The series is timely because the fundamental philosophies that guide management of patients with SUDs have evolved rapidly over the past decade. How can anesthesiologists begin to more adequately address the unmet needs of patients with SUDs in the perioperative period?” ask Akash Goel, MD, MPH, Department of Anesthesiology and Pain Medicine, University of Toronto, and Wiplove Lamba, MD, Department of Psychiatry University of Toronto, in an editorial overview of the series.

Recommendations for expanded involvement in managing patients with SUDs

As management of SUDs has evolved, anesthesiologists have become increasingly recognized as necessary to that management. The series ask readers to look at SUDs and SUDs treatment through the lens of a wide range of biopsychosocial factors and encourages a broader approach to effective disease management. For example, one article points out how discontinuing buprenorphine, a commonly used analgesic for reducing cravings, may actually increase opioid use during the perioperative period.

Goel and Lamba offer recommendations for how anesthesiologists can contribute meaningfully to improving outcomes for patients with a SUD. Trauma-informed patient care is critical. For example, during the pre-operative period understanding through direct discussion with a patient how their previous traumatic experiences might inform their perioperative experience and the need for a personalized pain management plan. Increased collaboration with patients, experts in Addiction Medicine and Psychiatry, patient advocacy groups, primary care providers, and other care partners is also key. In addition, with advances in treatment and the growing importance of socio-demographic factors, educational assets for anesthesiologists should be updated with content specific to addiction. Finally, the authors urge anesthesiologists to start viewing their role as one beyond pain management. Greater involvement in harm reduction interventions and surgical rehabilitation are two suggested areas.

Need for outcomes measurement to assess new approaches

The continuing evolution of both our understanding of addiction and substance abuse, and SUD management make high-quality studies and randomized controlled trials challenging. Objectives of these new approaches are to prevent relapse, reduce harm, minimize pain, and improve the overall well-being of people with SUDs. Goel and Lamba are proposing a system where relevant decision makers (patients, substance use experts) and appropriate stakeholders are involved in the policies and decisions that affect persons with SUDs.

Read the Substance Use Disorders issue of Anesthesia & Analgesia.

Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. We support clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions. For more information about our solutions, visit https://www.wolterskluwer.com/en/health and follow us on LinkedIn and Twitter @WKHealth.

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About Anesthesia & Analgesia

Anesthesia & Analgesia is the is the official journal of the International Anesthesia Research Society. The journal provides the practice-oriented, clinical research needed to keep current and provide optimal care to patients. Each monthly issue includes peer reviewed articles on the latest advances in drugs, preoperative preparation, patient monitoring, pain management, pathophysiology, and many other timely topics.

About the International Anesthesia Research Society

The International Anesthesia Research Society is a nonpolitical, not-for-profit medical society founded in 1922 to advance and support scientific research and education related to anesthesia, and to improve patient care through basic research. The IARS contributes more than $1 million annually to fund anesthesia research; provides a forum for anesthesiology leaders to share information and ideas; maintains a worldwide membership of physicians, physician residents, and others with doctoral degrees, as well as health professionals in anesthesia-related practice; sponsors the SmartTots initiative in partnership with the FDA; and publishes the monthly journal Anesthesia & Analgesia and its companion journal, A&A Practice, semi-monthly.

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 Wolters Kluwer reported 2022 annual revenues of €5.5 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 20,900 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

For more information, visit www.wolterskluwer.com, follow us on LinkedIn, Twitter, Facebook, and YouTube.

Newswise — One Virginia Tech researcher wants to spread awareness about the science of breastfeeding, particularly for pregnant women with opioid use disorder and their advocates. August is National Breastfeeding Month, which celebrates mothers and lactating parents and spreads awareness to support breastfeeding and human milk feeding.

Mothers should not breastfeed or express breast milk for their infants if they are using an illicit drug – such as non-prescription opioids, PCP (phencyclidine) or cocaine. But for those who have stopped using those substances and are on stable methadone or buprenorphine opioid use disorder therapy, breastfeeding should be encouraged, according to the Centers for Disease Control.

“There is so much stigma and misinformation, even among medical professionals, around opioid use disorder that people who are pregnant often don’t get the help they need,” said Brittany Howell, an assistant professor at the Fralin Biomedical Research Institute at VTC. Howell has studied the impact of opioid exposure during pregnancy and how it affects babies’ gut and brain development. She is available to answer such questions as:

• How does stigma keep women from breastfeeding? Stigma and misinformation surrounding opioid use disorder can prevent people from getting the care they need. “We have heard a lot of horror stories about well-meaning but poorly informed friends or family members, and about women’s experience in clinics. Where there is limited access to health care, people seeking care for a pregnancy have no choice but to keep going to providers who they know have given them bad advice. The care is not always informed by science.”
• How can society better support nursing mothers, particularly those who have the added challenge of a substance use disorder? “There are obstetricians who also have expertise as addiction specialists. We also know that babies with neonatal abstinence syndrome cry more, don’t eat well, and don’t sleep well. Some babies are fussier than others, but in this case we know why. Having a dedicated space for opioid exposed babies and nursing mothers who face the same struggles, and are there to support each other, can help. Having medical providers who understand their challenges and can offer support free from judgment makes a difference.”
• How does opioid exposure affect infants? “The biggest consensus is that the environment is way more important than the exposure,” Howell says. When advocates can address the factors that contribute to illicit use, women have been successful in quitting those substances.

Howell is leading a team of Virginia Tech researchers seeking to fill a knowledge gap: How do early exposure to opioids and other factors influence babies’ brain, physical, and behavioral development? Their work is part of the nationwide HEALthy Brain and Child Development study, which involves several National Institutes of Health institutes and centers and is part of the Helping End Addiction Long-term Initiative. Researchers will follow 7,500 moms and their children across the United States to gather data on pregnancy, infant and child development, growth, and bio-specimens.

About Howell
Brittany Howell is an assistant professor at the Fralin Biomedical Research Institute at VTC and the Virginia Tech Department of Human Development and Family Science. Her laboratory analyzes and compares breast milk composition, feeding practices, stress levels, fecal microbiology, social behavior, and brain imaging data to better understand maternal influence on infant neurodevelopment.

BYLINE: Matt Shipman

Newswise — A new study finds law enforcement officials play a critical role in launching programs designed to reduce the risk of repeat overdoses in people who use drugs. However, the study also raises concerns that law enforcement’s involvement in the outreach component of these programs may undermine program effectiveness.

At issue are post-overdose outreach programs, called post-overdose response teams in North Carolina, which are designed to reach out to people who have recently survived an overdose. Specifically, the goal of the programs is to connect survivors to available resources – such as harm reduction and treatment – that reduce their likelihood of overdosing again.

“We have programs and treatment tools that work to reduce harms associated with drug use, but we often struggle to connect people to these resources,” says Alexander Walley, co-author of the study and a professor of medicine at Boston University. “When a person overdoses, they are effectively flagging themselves as someone who could benefit from these harm reduction and treatment resources. Post-overdose outreach programs can help connect them to those resources.”

“These programs have expanded exponentially in recent years, and are likely to become even more common since they are eligible for funding from opioid settlement funds,” says Jennifer Carroll, an assistant professor of anthropology at North Carolina State University and corresponding author of the study. “However, best practices were not established for these programs until earlier this year, and we are still in the early stages of collecting evidence about how effective the programs are at actually doing what they aim to do.

“Our goal for this study was to get a better understanding of how these post-overdose programs are established and implemented,” Carroll says. “Basically, we want to know about their organizational infrastructure, why they’re organized this way or that way, and what seems to be helping or hurting the success of these programs.”

To that end, the researchers conducted 49 in-depth interviews with a variety of stakeholders involved in post-overdose outreach programs in Massachusetts. The study participants included 15 police officers; 23 community partners; eight overdose survivors who received outreach services; and three family members of overdose survivors who received outreach services.

“We found that access to law enforcement data is essential when getting post-overdose programs off the ground, because law enforcement data about suspected overdose events is unrestricted and not subject to any privacy laws that regulate medical information,” Carroll says. “It is crucial for programs to have the ability to identify and contact people who have recently survived an overdose, and most outreach efforts are designed to rely on law enforcement agencies for that purpose.”

However, the study also found that most post-overdose programs include police or deputies as part of the outreach teams that contact overdose survivors.

“Having law enforcement participate in outreach poses a variety of challenges,” Carroll says. “For one thing, police are being asked to participate in a program they are not trained for – they are not social workers or public health experts. For another, police are primarily tasked with enforcing local, state and federal laws; overdose survivors have broken the law by using illegal drugs, and many survivors have had negative experiences with law enforcement. Altogether, this makes overdose survivors leery of working with police, and can also put police in morally or professionally conflicted positions.

“In other words, post-overdose programs have a ‘police paradox’ – relying on law enforcement for information and support, but struggling with the fact that police involvement during the outreach process makes it harder to get the necessary buy-in from survivors and meet the program’s overdose prevention goals,” Carroll says.

The concerns raised in this study about police involvement during the outreach process are not unfounded. A 2022 study, also co-authored by Carroll and Walley, found that police sometimes arrested overdose survivors flagged by overdose-response programs.

“Ultimately, these findings suggest that – if we really want to reduce overdose risks – law enforcement should not be part of the post-overdose outreach teams,” Carroll says. “These findings were central to establishing current best practices for outreach, but many post-overdose programs don’t appear to be following best practices when it comes to keeping police out of the outreach teams.”

Best practice guidance developed by this research group can be found at prontopostoverdose.org.

The paper, “The police paradox: A qualitative study of post-overdose outreach program implementation through public health-public safety partnerships in Massachusetts,” is published in the International Journal of Drug Policy. The paper was co-authored by Emily Cummins of Harvard University; Scott Formica of Social Science Research and Evaluation, Inc.; Traci Green of Brandeis University; Sarah Bagley of Boston Medical Center and Boston University; Leo Beletsky of Northeastern University; and David Rosenbloom and Ziming Xuan of Boston University.

The study was funded by the Centers for Disease Control and Prevention under grant R01CE003052.

BYLINE: Greg Bruno

Newswise — With opioid overdose deaths surging in the United States, many communities are in desperate need of solutions to bring down the body count. Among the most promising is strengthening prison reentry programs for highest-risk users, a Rutgers-led study has found.

“For people who use drugs and have been in prison for several years, the reentry period can be chaotic and disorienting,” said Grant Victor, an assistant professor in the Rutgers School of Social Work and lead author of the study published in the Journal of Offender Rehabilitation.

“Closing the health care services gap after release, especially for those with psychiatric and behavioral health issues, may improve people’s willingness to engage with opioid use treatment,” Victor said.

Incarceration is a significant risk factor for opioid-related deaths. A 2013 study found the likelihood of a fatal overdose is approximately 129 times greater for someone recently released from prison compared with the general population. Another study, led by Victor, found 20 percent of all opioid-related overdose deaths in one community involved people released from prison within three years.

To investigate risk factors and potential solutions, Victor and colleagues at Northern Arizona University and Wayne State University applied machine learning to data from a Midwestern reentry program for incarcerated individuals with co-occurring opioid use and a mental health disorder.

“There were two things that we wanted to understand,” Victor said. “First, what factors increase the likelihood someone will take medication for opioid use disorder in the month following their release from prison? And second, within this already vulnerable group, is there a subgroup that is at the highest risk of opioid death after release?”

The researchers found that people who were prescribed psychiatric medication in the months before to release were most likely to begin opioid use disorder treatment. A participant’s history with injection drug use was another causal factor: Those who reported using injection drugs were more likely to report seeking treatment post-release than people who didn’t inject drugs.

Among other things, the findings suggest safe syringe services within prisons should be expanded, Victor said. These services not only improve opioid use treatment engagement but are effective in mitigating the transmission of infectious diseases, such as HIV and hepatitis.

“Getting the most vulnerable people into a healthcare ecosystem following release seems to benefit those who are susceptible to opioid overdose,” Victor said. “We found that those who were engaged in psychiatric treatment had a higher likelihood of engaging opioid treatment programs.”

Few studies have described the positive relationship between psychiatric pharmacology treatment and opioid use treatment among a reentry population, Victor said. One reason: Opioid use reentry programs are rare in the U.S.

“These types of reentry programs don’t happen in most prison systems,” he said. “But our findings support previous research that shows if you engage with this population during incarceration, it’s associated with improved outcomes post-release.”

Given these findings, Victor said state and federal prison systems should consider improving their “cascade of care” for opioid use, such as implementing standardized screening tools to identify at risk individuals in prison and supporting robust and accessible services when they are released.

Newswise — DALLAS – Aug. 16, 2023 – Overdose deaths from opioids, including prescription painkillers and synthetics like fentanyl, continue to rise. According to the Centers for Disease Control and Prevention, an estimated 187 people in the U.S. die every day of opioid overdoses, most involving illicit and dangerous versions of fentanyl.

According to a survey conducted by health policy research group KFF in July and released in August, about 3 in 10 adults say they or a family member have been addicted to opioids.

To provide perspective on the evolving epidemic, we spoke with four experts at UT Southwestern Medical Center about the dangers of opioid addiction, how to recognize an overdose, and treatment options including Narcan, which was recently approved by the Food and Drug Administration to be sold over the counter.

Stacey Hail, M.D., FACMT, Associate Professor of Emergency Medicine in UTSW’s Division of Medical Toxicology, treats patients in the Emergency Department at Parkland Memorial Hospital and consults on toxicology patients through the North Texas Poison Center. Dr. Hail has a forensic toxicology practice and reviews opioid cases for the U.S. Department of Justice as well as for attorneys in civil matters.

Enas Kandil, M.D., Associate Professor of Anesthesiology and Pain Management, leads quality improvement projects on opioid safety initiatives at UTSW and Parkland Health, with the goal of regulating opioid-prescribing practices and ensuring hospital compliance, thus improving patient safety.

Sidarth Wakhlu, M.D., Professor of Psychiatry and a member of the Peter O’Donnell Jr. Brain Institute, specializes in the treatment of substance abuse disorders. He is Director of the Addiction Psychiatry Fellowship Program and Associate Director of the Addiction Division in Psychiatry.

Kurt Kleinschmidt, M.D., Professor of Emergency Medicine in the Division of Medical Toxicology, leads an Addiction Medicine team at UT Southwestern. He also is Medical Director of the Perinatal Intervention Program (PIP) at Parkland Health, which cares for pregnant women with substance abuse disorders, and Service Chief of the Integrated Family Planning Opioid Program at Parkland.

What are the signs of an opioid overdose?

Dr. Hail: We use a term in medical toxicology called toxidrome – “toxic” and “syndrome” mashed together. It’s defined as the constellation of signs and symptoms unique to a certain substance. In other words, overdosing on one type of drug looks different from overdosing on a drug in a different class. The opioid toxidrome consists of pinpoint pupils (very tiny pupils); central nervous system depression, which ranges from lethargy or sleepiness all the way to coma; and respiratory depression, where people breathe slower and shallower until they stop breathing and die. Respiratory depression is the most concerning aspect of opioid overdoses. Unconscious patients cannot protect their airway, and the airway tissue collapses, causing an obstructive breathing pattern. This sounds like snoring to lay people.

How do you treat a patient who has an opioid overdose?

Dr. Hail: If a person has pinpoint pupils, is unconscious, and is barely breathing and/or snoring, there is an antidote, called naloxone, that quickly reverses the opioid toxidrome. Narcan is the best-known form and is most frequently administered intravenously or through the nose. There is a substantial risk of death if Narcan is not administered expeditiously. Once a person stops breathing and no longer has a pulse, Narcan will not work. Narcan does not raise individuals from the dead. It does not reverse the effects of any other drug except opioids.

What is the significance of Narcan being available over the counter soon?

Dr. Kleinschmidt: The U.S. Food and Drug Administration approved sales of Narcan nasal spray over the counter in March 2023, but the rollout has not taken effect yet. Until they are made available over the counter, Narcan and other naloxone products can be obtained with a prescription or from the pharmacy counter by talking to a pharmacist. But patients should always check with the pharmacy on availability.

Dr. Kandil: This important move by the FDA has been supported by the American Medical Association and other societies such as the American Society of Anesthesiologists. A naloxone product is typically carried by all EMT personnel and police officers and is being made available in schools and areas of public gatherings.

Are there risks to using naloxone?

Dr. Kleinschmidt: It is a safe medication. The biggest problem is that it can put the patient into withdrawal. While withdrawal is not optimal, it is better than death. There are concerns that providing naloxone to patients who abuse opioids will encourage them to continue using drugs, as if we are giving them permission to use. This is simply not true. Patients with addiction will use opioids until they receive treatment; giving them naloxone will not change that in any way. Giving patients naloxone to take with them is harm reduction – it is given to reduce death. People who have overdosed will not be able to give naloxone to themselves; someone else must administer it.

Synthetics, including fentanyl, caused more than 82% of opioid deaths in 2020. What should people know about this deadly form of opioids?

Dr. Hail: Counterfeit pills are circulating on the streets of this country. They may be fake Percocet, Adderall, Xanax, and even aspirin. Heroin and cocaine are either tainted with fentanyl or are entirely fentanyl. Fentanyl is 100 times more potent than morphine and dangerous even to individuals who are tolerant of the effects of opioids. Because of the potency of fentanyl, most patients who overdose do not survive long enough to be transported to the emergency department. They are confirmed dead at the scene.

When do patients need opioids to manage their pain and what alternatives exist?

Dr. Kandil: Opioids are not intended as a first choice for pain control. The CDC recommends trying other non-habit-forming medications before turning to opioids. Alternatives such as NSAIDs (nonsteroidal anti-inflammatory drugs) and acetaminophen as well as topical analgesics should be considered. Massage therapy and ice therapy have been shown to be effective in reducing pain in certain conditions as well. If those fail, opioids should be considered, starting with the lowest effective dose for the shortest period possible.

What’s critical to know about the health risks from opioids?

Dr. Kandil: Opioids are beneficial in controlling pain when other modalities have failed. However, they should be used under direct supervision of a licensed health care provider as they are not without risks. Known short-term risks include respiratory depression, sedation, constipation, and tolerance, which may lead to dependence. Opioids also carry long-term health risks, including decreased immunity, weight gain, and decreased sex drive.

How can patients who are prescribed opioid medications avoid becoming addicted?

Dr. Kandil: Patients who use the medications as prescribed should not be concerned about addiction. They should regularly follow up with their provider and discuss any concerns. Patients should be careful about combining opioids with other respiratory depressant medications such as benzodiazepines and sedatives. Alcohol should also be avoided while taking an opioid.

Dr. Wakhlu: Men and women who have suffered preadolescent sexual/physical trauma or have a history of substance abuse disorder have a greater likelihood of developing an addiction to opioids. Childhood sexual trauma gives rise to post-traumatic stress disorder (PTSD), which is associated with substance use disorders and is two to three times more common in women than men. Any patient with a history of substance abuse disorder should share those details with their physician, who should have a discussion with the patient and their significant other about the addictive potential of opioid pain medications. This communication is critical to prevent misuse and abuse.

Why are opioids so addictive?

Dr. Wakhlu: Opioids can cause euphoria and a rush of energy for some people. Gradually people start using more and more opioids as they develop tolerance. When they stop using opioids cold turkey, they develop withdrawal symptoms characterized by anxiety, agitation, insomnia, irritability, runny nose, nausea, vomiting, diarrhea, and chills. Withdrawal from opioids is like a severe case of the flu.

How is opioid withdrawal most effectively treated?

Dr. Hail: Unlike alcohol withdrawal, which is life-threatening, opioid withdrawal is not life-threatening – but it is very uncomfortable. Opioid-dependent patients call this “dope sick.” In the ER, we treat the symptoms with anti-nausea, anti-diarrhea, and anti-anxiety medications, a drug called clonidine for drug craving, and IV fluids.

What makes a treatment program for opioid addiction effective?

Dr. Wakhlu: The best evidence for the management of opioid addiction is the combination of medication plus therapy, such as individual therapy and support groups like 12-step recovery meetings and SMART (Self-Management and Recovery Training). Medications like buprenorphine and methadone are beneficial for eliminating opioid withdrawal symptoms and cravings. Both are safe, effective medications that significantly decrease the risk of relapse and opioid overdose. The World Health Organization has placed them on its “Model List of Essential Medicines.” They should be taken long term. I like to use the analogy that a patient with diabetes needs insulin for day-to-day functioning. In the same vein, a patient with opioid addiction needs buprenorphine or methadone for stability and to significantly decrease the risk of relapse.

Opioids overdose data

• Between 1999 and 2022, U.S. overdose deaths from prescription opioids, heroin, and synthetic opioids such as fentanyl saw an eightfold increase.
• Opioids caused nearly 69,000 deaths in 2020 – almost 75% of drug overdose deaths that year.
• The deadliest synthetic opioid authorities have found, carfentanil, is estimated to be 10,000 times more potent than morphine – which is also an opioid.
• CDC data showed total drug overdose deaths in 2022 increased at least 9% in eight states compared with 2021 – including Texas at 11.1%. Opioid deaths decreased in two states severely affected by the crisis, West Virginia and Maryland.

Source: Centers for Disease Control and Prevention

Signs of an opioid overdose

• Constricted, pinpoint pupils
• Falling asleep or loss of consciousness
• Slow, shallow breathing
• Choking or gurgling sounds
• Limp body
• Pale, blue, or cold skin

Source: Centers for Disease Control and Prevention

Resources

About UT Southwestern Medical Center
UT Southwestern, one of the nation’s premier academic medical centers, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty has received six Nobel Prizes, and includes 26 members of the National Academy of Sciences, 19 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 2,900 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in more than 80 specialties to more than 100,000 hospitalized patients, more than 360,000 emergency room cases, and oversee nearly 4 million outpatient visits a year.

About Parkland Health
Parkland Health is one of the largest public hospital systems in the country. Premier services at the state-of-the-art Parkland Memorial Hospital include the Level I Rees-Jones Trauma Center, the only burn center in North Texas verified by the American Burn Association for adult and pediatric patients, and a Level III Neonatal Intensive Care Unit. The system also includes two on-campus outpatient clinics – the Ron J. Anderson, MD Clinic and the Moody Outpatient Center, as well as more than 30 community-based clinics and numerous outreach and education programs. By cultivating its diversity, inclusion, and health equity efforts, Parkland enriches the health and wellness of the communities it serves. For more information, visit parklandhealth.org.

Newswise — CHICAGO – Women are at significantly greater risk of depression following brain injury than men. People with opioid use disorder are nearly five times more likely to overdose following surgery. Black, Hispanic and Asian children are less likely to receive tubes commonly used to treat ear infections. These findings are among the significant research to be unveiled at ANESTHESIOLOGY® 2023, the annual meeting of the American Society of Anesthesiologists (ASA), Oct. 13-17 in San Francisco. 

ANESTHESIOLOGY® 2023, the premier anesthesiology event, will include: 

• Groundbreaking scientific research highlighted in more than 750 abstracts covering the best science in the field. 
• More than 350 educational sessions and panels including racial and ethnic disparities in health care; diversity, equity, and inclusion efforts within the specialty; the latest guidance for opioid use disorder and pain management therapies; sessions on pediatric anesthesia, postoperative delirium, regional anesthesia and more. 
• Barbara Scavone, M.D., will present the Gertie Marx Lecture “The Anesthesiologist’s Role on Labor and Delivery,” focusing on maternal health care and anesthesiologists’ impact in reducing maternal morbidity and mortality. 
• John Eichhorn, M.D., will present the Ellison Pierce Lecture “Integrating Behavior and Technology for Anesthesia Patient Safety,” demonstrating that human factors and safety-oriented culture, mindset and behaviors are the keys to maintaining and improving anesthesia safety. 
• An immersive exhibit hall spotlighting innovators and leaders in the specialty, hands-on educational opportunities, research insights, and the latest products, resources and services elevating anesthesiology care today.   

What: ANESTHESIOLOGY® 2023 When: Oct. 13-17 Where: Moscone Center, 747 Howard St., San Francisco, CA 94103 How to Register: To register, email [email protected] with your press credentials or a letter of assignment. Join the Conversation: You can join the conversation on social media by using #ANES23. 

THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 56,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/madeforthismoment. Like ASA on Facebook and follow ASALifeline on Twitter. 

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Newswise — The pendulum of opioid prescribing for pain has swung sharply in the last decade, as the epidemic of opioid overuse, addiction and overdose led policymakers and health care providers to ratchet back on the prescriptions patients receive.

But for about 5 million Americans who have taken prescription opioids for years to address their chronic pain, that pendulum swing has led to trouble getting refills, finding new providers when their former ones retire or relocate, or getting access to multimodal pain care that goes beyond pills.

In a new paper in the Journal of Pain Research, researchers from the University of Michigan describe the consensus of a wide range of experts about how to help patients with chronic pain get adequate pain care, and coverage for the cost of that care.

Specifically, the experts call for restructuring the insurance models under which health care providers get reimbursed for caring for people with chronic pain, enhancing education of health care providers in chronic pain care as well as identifying and treating opioid use disorder, and addressing racial inequities in care which are often rooted in stigma around pain and opioid use.

The experts, who came from many fields and many areas of Michigan, reviewed research on the issue and brought their own experience to a deliberative process known as a modified Delphi panel.

This allowed them to come to consensus on the most-needed and most-achievable changes, says study senior author Pooja Lagisetty, M.D., M.S., an assistant professor of internal medicine at Michigan Medicine, U-M’s academic medical center, and the VA Ann Arbor Healthcare System.

In addition to the new paper, Lagisetty was recently interviewed about current issues in opioids and care for chronic pain and opioid use disorder for the Michigan Medicine research podcast The Fundamentals.

She, and the experts involved in the newly published paper, emphasize the importance of helping patients who have taken opioids for long periods of time get access to the gold-standard for chronic pain care.

Called multi-modal pain care, it involves not just oral pain medications but physical therapy, cognitive behavioral therapy, injected pain therapies and integrative medicine techniques including acupuncture and chiropractic care.

This requires both training and payment for the multiple types of health care professionals – physicians, nurse practitioners, physician assistants, psychologists, physical therapists, social workers and others – who can team up to provide such care.

“In order to encourage more clinics to offer multimodal pain care and increase access for patients who currently don’t receive it, insurance companies and government health coverage programs such as Medicaid need to change how they pay for it,” says Lagisetty. “We are starting to see some change, most notably at the VA and in insurance coverage of physical therapy, but more is needed in order for patients and providers to have time to develop individualized approaches, overcome stigma around providing opioid-related care, and for clinics to begin offering non-medication services.”

Lagisetty notes that the new physician payment rule proposed for Medicare appears to pave the way for reimbursement for more comprehensive pain management care. But increasing access also requires training more providers in how to provide such care effectively.

Such care is in line with the opioid-related guidelines released last fall by the Centers for Disease Control and Prevention, which emphasize patient-centered care and an individualized, rather than broadly mandated, approach to prescribing opioids to patients.

The prior CDC guidelines were issued in 2016 in reaction to the role of prescription opioids in fueling addiction and overdose. Although intended as guidance rather than rules, they became the basis for policies and clinical practices that inadvertently closed doors to care for chronic pain patients, Lagisetty notes.

Without access to care and medication, patients may seek prescription and non-prescription opioids through unauthorized channels, leading to worsened risks of addiction, overdose and mental health, she adds. The lack of availability of care for opioid use disorder, which traces its roots to stigma and administrative hurdles, makes the issue worse, she says.

In addition to Lagisetty, the study’s authors include Adrianne Kehne of the VA Center for Clinical Management Research, of which Lagisetty is a member, and several U-M faculty members who like Lagisetty are members of the U-M Institute for Healthcare Policy and Innovation: Steven J Bernstein, M.D., M.P.H., Mark C Bicket, M.D., Ph.D., and Amy Bohnert, Ph.D., as well as Erin Fanning Madden of Wayne State University, and U-M’s Jennifer Thomas and Victoria Powell, M.D.

The expert consensus process was funded by the Michigan Health Endowment Fund, the National Institute on Drug Abuse (DA047475) and the National Institute on Aging (AG062043).

Paper: Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan, Journal of Pain Research, 16:, 2321-2330, DOI: 10.2147/JPR.S406034

Related IHPI Brief: https://ihpi.umich.edu/paincare

Newswise — In much the same way that meteorologists have become more sophisticated in forecasting the weather, researchers at Tufts University School of Medicine, led by professor Thomas J. Stopka in the Department of Public Health and Community Medicine, are using their research to better predict spikes in opioid-related overdoses and address HIV and hepatitis C infections.

Opioid-related overdoses continue to be at crisis levels in communities across the United States, with more than 75,673 fatal overdoses in the 12-month period ending in April 2021. Stopka and his colleagues believe that using the predictive power of their research to study the patterns of overdoses and heightened infections in those using drugs can save lives.

Their goal is to provide timely alerts to people who have substance use disorders, their families, public health, public safety, and social services agencies in hopes of blunting the number of deaths and serious illnesses that result when a new drug hits and disrupts the illicit drug supply.

In a situation where every hour counts, research by Stopka and co-principal investigators Shikhar Shrestha and Jennifer Pustz, N19, MG19, is helping the City of Lowell, Massachusetts, cut in half the time it takes to identify an uptick in opioid overdoses and to alert those in danger more effectively. Shrestha is an assistant professor and Pustz was a researcher in the Department of Public Health and Community Medicine when the study began. New predictive model research may make it possible to identify risks of overdoses at the level of individual ZIP codes in the future, Stopka adds.

Another Tufts study is identifying ways to decrease the risk of overdose among people recently released from jail or prison. And yet another effort, along the Interstate-91 corridor in New Hampshire and Vermont, is developing new interventions that the researchers hope will slow the spread of HIV and the hepatitis C virus among people who inject drugs.

Earlier Alerts Slowing Overdoses in Lowell

Drug overdoses increase when a new adulterant or cut is introduced into substances already being sold on the streets. The greatest risk occurs when fentanyl is in the mix. Fentanyl was first introduced in Eastern Massachusetts around 2013. Then it moved to southeastern Massachusetts and arrived later in western Massachusetts.

Stopka and colleagues saw an uptick in overdoses in Lowell, Massachusetts, and the Merrimack Valley when fentanyl arrived, replacing heroin as the drug of choice for many people with substance use disorders. More recently, xylazine, an animal tranquilizer also called Tranq, has been in the news as it makes its way into the drug supply. Mixed with fentanyl, it can put people to sleep for hours, lessening the frequency of their need. (Often, they don’t seek out drugs just for a high, but rather to not feel sick from withdrawal). But it can result in fatal drug poisonings and naloxone (Narcan®) may not reverse its effects.

Shrestha, Pustz, and Stopka, along with colleagues from the University of Massachusetts Lowell, and city agencies and non-profits, are focused on better understanding opioid alert programs. These programs are used by police departments, fire departments, public health officials and others who seek to warn people with substance use disorders when trouble is brewing in the drug supply.

In one such effort, the researchers observed that when 18 overdoses occurred in Lowell over a period of 72 hours, an alert system would be triggered that would include a press release to the news media, postings on social media, and other traditional routes to communicate news to the public. “But the messages weren’t getting to the people using drugs, their families, and peers soon enough,” Stopka says.

Using EMS data from Trinity EMS, the major ambulance service in Lowell, the team is developing and testing predictive models that could signal a problem in as quick as 36 hours that there has been a spike in overdose deaths. The models aim to help Lowell officials get the alerts out faster—through traditional media, social media, and other channels—to reach people who are at risk of overdose. They also aim to reach organizations working with people who use drugs and peer groups, including syringe services programs, methadone maintenance programs, soup kitchens, and shelters.

“The goal of the study is to not just reduce the time it takes to detect a spike in opioid overdose, but also to understand how alert messages are communicated among stakeholders and people with substance use disorders and how they act on the shared information,” says Shrestha. “The research will help us develop and share a streamlined protocol that reduces the time to detect overdose spikes and then share the messages efficiently in the affected community.”

Predicting Overdoses by ZIP Code

Stopka and fellow principal investigator Cici Bauer, associate professor at the University of Texas Health Sciences Center in Houston, along with Olaf Dammann, professor and vice chair of the Department of Public Health and Community Medicine at the School of Medicine, are working to develop spatiotemporal prediction models relying on vast amounts of data to forecast fatal opioid-related overdoses at a granular level—as detailed, perhaps, as particular ZIP codes. This work is also being done with researchers at Boston University, the University of Massachusetts Lowell, the Massachusetts Department of Public Health, as well as a community advisory board comprised of experts from state and local public health departments, healthcare facilities, community-based agencies, and harm reduction programs.

“Current forecasting models focus on predicting overdoses on a large geographical scale, such as states or counties,” Stopka says. “They lack the granularity that could really help local public health officials guide decisions and resources.”

“In the same way that meteorologists try to predict where hurricanes and tornadoes are going to hit, we want to develop predictive models so people can make themselves safe by responding before the big hurricane of overdoses hits,” he concludes. The goal is to be able to inform public health responses that could flood an area experiencing an overdose spike with safe syringes, Narcan, and medications for opioid use disorder to help people begin treatment.

The Jail-to-Community Transition

Another effort by researchers at the School of Medicine is focused on improving the transition from jail or prison to the community for incarcerated individuals with opioid use disorders. People released from jail or prison are 120 times more likely to overdose on opioids than the general population in Massachusetts. A recent study by Stopka and fellow principal investigators from the University of Massachusetts—Elizabeth Evans, assistant professor at UMass Amherst, and Peter Friedmann, professor at UMass Baystate—suggests at least three ways a new, jail-based opioid use disorder treatment program in seven county jails in Massachusetts can be improved to reduce that risk.

“If someone starts treatment with methadone or another opioid disorder treatment while in jail, and then is released without proper planning, they may relapse before getting continued treatment back in the community,” Stopka explains. “And if they attempt to use opioids at levels comparable to what they previously used, at a time when their tolerance is much lower, overdoses often result.”

But giving incarcerated individuals bridge doses of medication to cover them until they can connect with a community treatment program—and making sure they have a cellphone to contact that program to make an appointment—are key to preventing overdoses during the transition.

“The justice system in Massachusetts is at the forefront of public health innovation,” says Evans. “And we’re learning whether a program like this is effective, how it can be implemented, and what it costs, which is information that can help legislators know whether to continue the program or replicate it elsewhere in other states.”

Using a Van to Slow HIV and Hepatitis C

Stopka and Friedmann are also multi-principal investigators for one of eight groups nationally participating in a program funded by the National Institutes of Health to see if improved access to diagnostic and treatment services can slow infectious diseases associated with drug use in rural communities. In this study, the Tufts and UMass Chan-Baystate team is working along the I-91 corridor in Western New Hampshire and Vermont to test a mobile telemedicine-based hepatitis C virus treatment to assess its effectiveness among rural populations of people with substance use disorders.

“While some people may think of the opioid epidemic as a predominantly urban problem, the hepatitis C and overdose rates are also elevated in rural areas when accounting for population density. The cause is a lack of access to treatment and prevention services,” says Stopka.

“What we’ve learned over the years is that in both urban and rural areas, drugs are more accessible and less expensive than drug treatment. And when people are ready to get into drug treatment programs, supply of treatment slots rarely outpace demand. Hepatitis C virus treatment and overdose prevention services and drug treatment are less available and are further away in rural areas.”

In the I-91 corridor project, using a van, the team offers screening for HIV and hepatitis C. The van is equipped with internet services connected to telemedicine clinicians at Dartmouth-Hitchcock Medical Center in New Hampshire. “The goal is to demonstrate the effectiveness of bringing needed hepatitis C treatment and harm reduction services to rural areas where the need is great and lack of transportation is a major barrier to care,” says Friedmann.

Some of those in the study who test positive are randomly assigned to enhanced usual care that includes care navigation and referral for treatment and follow-up at the nearest provider, which can be several towns away. They are also offered free sterile syringes and referrals, if they want, to harm-reduction programs, which use humility and compassion to engage with people who have substance use disorders to improve their overall wellbeing.

Those who are randomized to the experimental group get immediate advice via telemedicine from Better Life Partners clinicians, and prescriptions for anti-viral medications to treat their hepatitis C infection. Those in the experimental arm of the study can then return to the van—near where they normally hang out—for follow up over at least 8-12 weeks, rather than needing to travel a distance for care and follow-up.

“Our team is exceptional. They’re listening and providing support every week,” says Stopka. “We are adjacent to other agencies that clients visit anyway, such as homeless shelters and places that provide meals. We have identified strong local partners who are fixtures in the community, and from whom we learn every day.”

Results of this study are still a year away. But Stopka is hopeful.

“If we can decrease the pool of infected people, that means they, in turn, are infecting fewer other people,” he says. “That’s a huge win. Together with the work we are doing to predict when and where overdoses are happening, we can begin to imagine concrete ways to really slow the devastation caused by opioids in the years ahead.”

Related links:

https://now.tufts.edu/2022/08/11/improving-release-process-incarcerated-people-may-help-reduce-opioid-overdoses

https://now.tufts.edu/2021/09/21/tracking-shifting-landscape-opioid-crisis

https://now.tufts.edu/2020/03/11/what-opioid-use-rats-can-tell-us-about-addiction-humans

Research reported in this article was supported by the National Institutes of Health’s National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention under awards 4UG3-UH3 DA044830-03, UM1DA04912, UG1DA050067, 1NU1ROT000018-01-00. Complete information on authors, funders, and conflicts of interest for these projects are available in the published papers here. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.