Addiction Medicine

The Centers for Disease Control and Prevention reported that an estimated 100,306 Americans died from drug overdoses during the period from April 2020 to April 2021, a 28.5% increase from the previous year.

Deaths in some states rose even more precipitously. Vermont saw an almost 70% increase, and drug overdose deaths in West Virginia increased by 62%. Many states, including Alabama, California, Kansas, Kentucky, Louisiana, Tennessee, and Washington, had a 45%-50% rise in overdose deaths.

The data released by the CDC was provisional, as there is generally a lag between a reported overdose and confirmation of the death to the National Vital Statistics System. The agency uses statistical models that render the counts almost 100% accurate, the CDC says.

The vast majority (73,757) of overdose deaths involved opioids – with most of those (62,338) involving synthetic opioids such as fentanyl. Federal officials said that one American died every 5 minutes from an overdose, or 265 a day.

“We have to acknowledge what this is – it is a crisis,” Department of Health & Human Services Secretary Xavier Becerra told reporters on a call.

“As much as the numbers speak so vividly, they don’t tell the whole story. We see it in the faces of grieving families and all those overworked caregivers. You hear it every time you get that panicked 911 phone call, you read it in obituaries of sons and daughters who left us way too soon,” Mr. Becerra said.

Rahul Gupta, MD, director of the White House Office of National Drug Control Policy, said that “this is unacceptable, and it requires an unprecedented response.”

Dr. Gupta, who noted that he has a waiver to treat substance use disorder patients with buprenorphine, said he’s seen “first-hand the heartbreak of the overdose epidemic,” adding that, with 23 years in practice, “I’ve learned that an overdose is a cry for help and for far too many people that cry goes unanswered.”

Both Mr. Becerra and Dr. Gupta called on Congress to pass President Joe Biden’s fiscal 2022 budget request, noting that it calls for $41 billion – a $669 million increase from fiscal year 2021 – to go to agencies working on drug interdiction and substance use prevention, treatment, and recovery support. 

Dr. Gupta also announced that the administration was releasing a model law that could be used by state legislatures to help standardize policies on making the overdose antidote naloxone more accessible. Currently, such policies are a patchwork across the nation.

In addition, the federal government is newly supporting harm reduction, Mr. Becerra said. This means federal money can be used by clinics and outreach programs to buy fentanyl test strips, which they can then distribute to drug users.

“It’s important for Americans to have the ability to make sure that they can test for fentanyl in the substance,” Dr. Gupta said.
 

Fake pills, fentanyl a huge issue

Federal officials said that both fentanyl and methamphetamine are contributing to rising numbers of fatalities.

“Drug cartels in Mexico are mass-producing fentanyl and methamphetamine largely sourced from chemicals in China and they are distributing these substances throughout the United States,” Anne Milgram, administrator of the Drug Enforcement Administration, said on the call.

Ms. Milgram said the agency had seized 12,000 pounds of fentanyl in 2021, enough to provide every American with a lethal dose. Fentanyl is also mixed in with cocaine, heroin, methamphetamine, and marijuana – often in counterfeit pills, Ms. Milgram said.

The DEA and other law enforcement agencies have seized more than 14 million such pills in 2021. “These types of pills are easily accessible today on social media and e-commerce platforms, Ms. Milgram said.

“Drug dealers are now in our homes,” she said. “Wherever there is a smart phone or a computer, a dealer is one click away,” Ms. Milgram said.

National Institute on Drug Abuse Director Nora D. Volkow, MD, said that dealers will continue to push both fentanyl and methamphetamine because they are among the most addictive substances. They also are more profitable because they don’t require cultivation and harvesting, she said on the call.

Dr. Volkow also noted that naloxone is not as effective in reversing fentanyl overdoses because fentanyl is more potent than heroin and other opioids, and “it gets into the brain extremely rapidly.”

Ongoing research is aimed at developing a faster delivery mechanism and a longer-lasting formulation to counter overdoses, Dr. Volkow said.

A version of this article first appeared on Medscape.com.

The Centers for Disease Control and Prevention reported that an estimated 100,306 Americans died from drug overdoses during the period from April 2020 to April 2021, a 28.5% increase from the previous year.

Deaths in some states rose even more precipitously. Vermont saw an almost 70% increase, and drug overdose deaths in West Virginia increased by 62%. Many states, including Alabama, California, Kansas, Kentucky, Louisiana, Tennessee, and Washington, had a 45%-50% rise in overdose deaths.

The data released by the CDC was provisional, as there is generally a lag between a reported overdose and confirmation of the death to the National Vital Statistics System. The agency uses statistical models that render the counts almost 100% accurate, the CDC says.

The vast majority (73,757) of overdose deaths involved opioids – with most of those (62,338) involving synthetic opioids such as fentanyl. Federal officials said that one American died every 5 minutes from an overdose, or 265 a day.

“We have to acknowledge what this is – it is a crisis,” Department of Health & Human Services Secretary Xavier Becerra told reporters on a call.

“As much as the numbers speak so vividly, they don’t tell the whole story. We see it in the faces of grieving families and all those overworked caregivers. You hear it every time you get that panicked 911 phone call, you read it in obituaries of sons and daughters who left us way too soon,” Mr. Becerra said.

Rahul Gupta, MD, director of the White House Office of National Drug Control Policy, said that “this is unacceptable, and it requires an unprecedented response.”

Dr. Gupta, who noted that he has a waiver to treat substance use disorder patients with buprenorphine, said he’s seen “first-hand the heartbreak of the overdose epidemic,” adding that, with 23 years in practice, “I’ve learned that an overdose is a cry for help and for far too many people that cry goes unanswered.”

Both Mr. Becerra and Dr. Gupta called on Congress to pass President Joe Biden’s fiscal 2022 budget request, noting that it calls for $41 billion – a $669 million increase from fiscal year 2021 – to go to agencies working on drug interdiction and substance use prevention, treatment, and recovery support. 

Dr. Gupta also announced that the administration was releasing a model law that could be used by state legislatures to help standardize policies on making the overdose antidote naloxone more accessible. Currently, such policies are a patchwork across the nation.

In addition, the federal government is newly supporting harm reduction, Mr. Becerra said. This means federal money can be used by clinics and outreach programs to buy fentanyl test strips, which they can then distribute to drug users.

“It’s important for Americans to have the ability to make sure that they can test for fentanyl in the substance,” Dr. Gupta said.
 

Fake pills, fentanyl a huge issue

Federal officials said that both fentanyl and methamphetamine are contributing to rising numbers of fatalities.

“Drug cartels in Mexico are mass-producing fentanyl and methamphetamine largely sourced from chemicals in China and they are distributing these substances throughout the United States,” Anne Milgram, administrator of the Drug Enforcement Administration, said on the call.

Ms. Milgram said the agency had seized 12,000 pounds of fentanyl in 2021, enough to provide every American with a lethal dose. Fentanyl is also mixed in with cocaine, heroin, methamphetamine, and marijuana – often in counterfeit pills, Ms. Milgram said.

The DEA and other law enforcement agencies have seized more than 14 million such pills in 2021. “These types of pills are easily accessible today on social media and e-commerce platforms, Ms. Milgram said.

“Drug dealers are now in our homes,” she said. “Wherever there is a smart phone or a computer, a dealer is one click away,” Ms. Milgram said.

National Institute on Drug Abuse Director Nora D. Volkow, MD, said that dealers will continue to push both fentanyl and methamphetamine because they are among the most addictive substances. They also are more profitable because they don’t require cultivation and harvesting, she said on the call.

Dr. Volkow also noted that naloxone is not as effective in reversing fentanyl overdoses because fentanyl is more potent than heroin and other opioids, and “it gets into the brain extremely rapidly.”

Ongoing research is aimed at developing a faster delivery mechanism and a longer-lasting formulation to counter overdoses, Dr. Volkow said.

A version of this article first appeared on Medscape.com.

The Centers for Disease Control and Prevention reported that an estimated 100,306 Americans died from drug overdoses during the period from April 2020 to April 2021, a 28.5% increase from the previous year.

Deaths in some states rose even more precipitously. Vermont saw an almost 70% increase, and drug overdose deaths in West Virginia increased by 62%. Many states, including Alabama, California, Kansas, Kentucky, Louisiana, Tennessee, and Washington, had a 45%-50% rise in overdose deaths.

The data released by the CDC was provisional, as there is generally a lag between a reported overdose and confirmation of the death to the National Vital Statistics System. The agency uses statistical models that render the counts almost 100% accurate, the CDC says.

The vast majority (73,757) of overdose deaths involved opioids – with most of those (62,338) involving synthetic opioids such as fentanyl. Federal officials said that one American died every 5 minutes from an overdose, or 265 a day.

“We have to acknowledge what this is – it is a crisis,” Department of Health & Human Services Secretary Xavier Becerra told reporters on a call.

“As much as the numbers speak so vividly, they don’t tell the whole story. We see it in the faces of grieving families and all those overworked caregivers. You hear it every time you get that panicked 911 phone call, you read it in obituaries of sons and daughters who left us way too soon,” Mr. Becerra said.

Rahul Gupta, MD, director of the White House Office of National Drug Control Policy, said that “this is unacceptable, and it requires an unprecedented response.”

Dr. Gupta, who noted that he has a waiver to treat substance use disorder patients with buprenorphine, said he’s seen “first-hand the heartbreak of the overdose epidemic,” adding that, with 23 years in practice, “I’ve learned that an overdose is a cry for help and for far too many people that cry goes unanswered.”

Both Mr. Becerra and Dr. Gupta called on Congress to pass President Joe Biden’s fiscal 2022 budget request, noting that it calls for $41 billion – a $669 million increase from fiscal year 2021 – to go to agencies working on drug interdiction and substance use prevention, treatment, and recovery support. 

Dr. Gupta also announced that the administration was releasing a model law that could be used by state legislatures to help standardize policies on making the overdose antidote naloxone more accessible. Currently, such policies are a patchwork across the nation.

In addition, the federal government is newly supporting harm reduction, Mr. Becerra said. This means federal money can be used by clinics and outreach programs to buy fentanyl test strips, which they can then distribute to drug users.

“It’s important for Americans to have the ability to make sure that they can test for fentanyl in the substance,” Dr. Gupta said.
 

Fake pills, fentanyl a huge issue

Federal officials said that both fentanyl and methamphetamine are contributing to rising numbers of fatalities.

“Drug cartels in Mexico are mass-producing fentanyl and methamphetamine largely sourced from chemicals in China and they are distributing these substances throughout the United States,” Anne Milgram, administrator of the Drug Enforcement Administration, said on the call.

Ms. Milgram said the agency had seized 12,000 pounds of fentanyl in 2021, enough to provide every American with a lethal dose. Fentanyl is also mixed in with cocaine, heroin, methamphetamine, and marijuana – often in counterfeit pills, Ms. Milgram said.

The DEA and other law enforcement agencies have seized more than 14 million such pills in 2021. “These types of pills are easily accessible today on social media and e-commerce platforms, Ms. Milgram said.

“Drug dealers are now in our homes,” she said. “Wherever there is a smart phone or a computer, a dealer is one click away,” Ms. Milgram said.

National Institute on Drug Abuse Director Nora D. Volkow, MD, said that dealers will continue to push both fentanyl and methamphetamine because they are among the most addictive substances. They also are more profitable because they don’t require cultivation and harvesting, she said on the call.

Dr. Volkow also noted that naloxone is not as effective in reversing fentanyl overdoses because fentanyl is more potent than heroin and other opioids, and “it gets into the brain extremely rapidly.”

Ongoing research is aimed at developing a faster delivery mechanism and a longer-lasting formulation to counter overdoses, Dr. Volkow said.

A version of this article first appeared on Medscape.com.

If you are a psychiatrist who has done a public lecture in the past year, you likely encountered the question, “What about Britney’s conservatorship?” Many psychiatrists are far removed from conservatorship evaluations, doing the different yet still important work of alleviating mental suffering without paddling in the controversial waters of involuntary treatment. Others judiciously hide behind the veil of the prudent Goldwater Rule in avoiding such discussions altogether. Regardless of whether psychiatry attempts to stay out of such affairs publicly, our field remains intimately involved in the process itself. This can lead to negative views of psychiatry among the public – that of a medical specialty with ulterior motives operating at the behest of the state.

Some psychiatrists simplistically advocate against any form of involuntary treatment.¹ In many ways, this may appear noble. However, the reality of mental illness, with its potential harm to self and others, introduces the potential for dire consequences of such a position. If society is unwilling to accept behavior that may lead to harm, but psychiatry is unwilling to intervene, then other avenues of restricting such behavior will emerge. Those avenues traditionally have included conscription of law enforcement and the incarceration of patients with mental illness.

Yet, therein lies the conundrum of Ms. Spears and other celebrities on conservatorship. At face value, they do not appear to require conservatorship. We do not think it violates the Goldwater Rule to render this observation. In fact, it may reassure the public if the American Psychiatric Association, as well as individual psychiatrists, were more open about the goal, intent, and limitations of conservatorships.

The process of establishing conservatorships is not driven solely by mental health professionals. Rather, conservatorship laws permit society to enact, through psychiatrists, its desire to alleviate behaviors considered unacceptable in the context of mental illness.

In California, it has resulted in our famous or infamous “5150,” which asks psychiatrists to comment on the danger to self, danger to others, and grave disability of our patients. It can be helpful to frame these criteria regarding the relationship between society and our patients. The criteria of danger to self represents society’s wish to intervene in cases of patients with imminent intent of self-harm, operating under the presumption that a suicide can be prevented. Danger to others represents the societal angst, at times exaggerated,² about people with mental illness perpetuating homicides, especially when off their medication. Grave disability represents public shame at the thought of persons so lost to mental illness they are unable to provide for themselves or even accept food, clothing, and shelter.

While an involuntary hold is necessary at times, working against our patients engenders revolting feelings. We often rationalize involuntary holds as illustrative of sincere compassion for our patients’ suffering and an attempt to lift them out of such tragic conditions. Our patients regularly do not feel our compassion when we are making an argument in a hearing for the restriction of their rights. They see our efforts as an attempt to lock them away “for their own good” because of society’s discomfort with homelessness. As such, we wonder whether our role becomes one of doctors for society, prescribing a treatment for the emotional distress of the community, and at times for ourselves, rather than that of the patient.

One may be perplexed as to how a celebrity could be considered gravely disabled. Celebrities generally have enough income to afford food, clothing, and shelter. One could justifiably ask why an individual with no history of violence would be considered a danger to others. Similarly, one may wonder how, in the absence of any reported attempts to engage in self-harm, with no visible marks of self-harm, someone is determined to be a danger to himself or herself. The bafflement on the part of one on the outside of these determinations can be sharply contrasted by the desperation felt by family members whose loved ones with mental illness appear to meet those criteria yet are consistently turned away by mental health programs and hospitals.

Not uncommonly, it is families advocating for involuntary hospitalization – while lamenting our strict criteria – that prevent doctors from intervening until some tragic fate befalls their loved ones. They criticize what they consider to be too-stringent mental health laws and are infuriated by seemingly obtuse insurance policies limiting care to patients. Most of our colleagues working with those who have severe mental illness share the frustration of these families over the scarcity of psychiatry beds. Therefore, it is particularly shocking when the most mediatized story about conservatorship is not about how hard it is to obtain. The story is about a singer who was seemingly safe, caring for herself, and yet still ended up on a conservatorship.

We wonder whether there is a question of magnitude. Are homeless patients more difficult to place on conservatorship because society sees a lesser stake? One could argue that Ms. Spears and other celebrities would have so much to lose in a single episode of mental illness. A week with mania or psychosis could cause irreparable damage to their persona, opportunity for employment, and their fortune. On the contrary, many of our patients on conservatorship have little to their names, and no one keeping up on their reputation. Triers of facts should ask themselves about the nature of their motivations. Envy, a desire to live vicariously through celebrities, or even less ethical motivations – such as a desire to control and exert authority over those individuals – can influence our decisions.

Throughout the past year, when asked about Ms. Spears, we have pointed out the obvious – she seemingly has a life incompatible with meeting criteria for a psychiatric conservatorship. We have outlined the role, history, and limitations of psychiatric conservatorship. We have shared how such cases are often approached, when required for our own patients or when asked by the court to do so. We have discussed the significant oversight of the system, including the public conservator’s office, which frequently refuses petitions outright. There are hearing officers, who, in the early stages of this process, weigh our case against that of the patients, aided by passionately driven patient advocates. There is the public defender’s office, which, at least in San Diego, vigorously defends the rights of those with mental illness. Most importantly, there are judges who adjudicate those cases with diligence and humility.

As the story has continued to be in the news, we have had numerous conversations about Ms. Spears’ conservatorship with colleagues sharing strong opinions on her case. Many of these colleagues do not have forensic practices and we inevitably find ourselves responding along the lines of, “It is easy to say this, but quite a different thing to prove it in court.” It is hard not to imagine testifying in such a high-profile conservatorship case; testifying, in front of jurors, about a celebrity who may have engaged in what some considered to be unusual behavior.

Conservatorship laws are not about the minutia or criteria of a specific mental health disorder. Patients do not meet criteria for conservatorship by having a certain number of delusional thoughts or a specific type of hallucination. Patients meet criteria for conservatorship because of state-enacted laws based on social factors – such as danger and self-care – the population wishes to treat, even if against the will of those treated. Under this light, one must recognize that a conservatorship trial is not just about mental illness but about how society wants to care for human beings. Psychiatric illness itself is not grounds for conservatorship. Oftentimes, severely ill patients win a hearing for grave disability by simply accepting a referral for housing, showing up to court clothed, and eating the meals provided at the hospital.

With understanding that these laws pertain specifically to behaviors resulting from mental illness that society finds unacceptable, the narrative of a celebrity conservatorship can be considered differently. The stories of celebrities being used and abused by deleterious beings and deleterious conditions have become a genre. Paul Prenter’s treatment of Freddie Mercury documented in the 2018 movie “Bohemian Rhapsody” and John Reid’s alleged betrayal of Elton John, who was suffering from a substance use disorder, documented in the 2019 movie “Rocketman,” are recent examples, among many.

Imagine yourself, as a juror, deciding on the fate of a celebrity. Would you require them to have lost all property, including the clothing on their backs, before intervening? Consider the next time you hear of a celebrity swindled from his or her fortune in a time of crisis and whether it would have been righteous to prevent it. We personally have, at times, argued for restraint in psychiatry’s desire to have more power. This concern extends not only to our ability to control people, but also our ability to force them into being subjected to psychotropic medications with well-known side effects.

At the same time, we remain cognizant of the magnified impact of adverse outcomes on public figures. John Hinckley Jr. did not attempt to murder a bystander; he attempted to kill the president of the United States when he shot at President Ronald Reagan in 1981. That incident led to considerable changes in our laws about insanity. More recently, society was particularly affected by Tom Hanks’ COVID-19 diagnosis. Mr. Hanks’ illness led to scientifically measurable changes in the public’s beliefs regarding the pandemic.³

On the other hand, and of equal importance to the desire to protect public figures from adverse events, is the risk that those same laws intended to protect will harm. From unsanitary asylums to disproportionate placements of minorities on psychiatric holds, we are concerned with unbridled control in the hands of those meant to cure and care. Sadly, there is also a cinematic genre of unprincipled and detrimental mental health treatment, from Brian Wilson’s treatment by his psychologist documented in “Love & Mercy,” to the upcoming “The Shrink Next Door,” featuring a psychiatrist swindling his patient.

With this additional understanding and analysis, we now ask our colleagues what it would take for them to intervene. Would a celebrity losing $100,000,000 because of mental illness constitute a form of grave disability despite remaining dressed? Would a celebrity engaging in significant drug use constitute a form of self-harm despite still recording albums? Would a celebrity failing to fulfill a social commitment to others, including children, constitute a form of harm to others? Those are not trivial questions to answer, and we are glad the Goldwater Rule reminds us of the limitations of speculating on people we do not know.

Nonetheless, the question of conservatorship is more complex than simply saying: “They make money; they have clothes on; this is absurd.” While this may be a catchy, compelling, and relevant argument, when confronted with a more complete narrative, triers of facts may feel compelled to intervene because, in the end, conservatorship laws are about what society is willing to accept rather than an enumeration of psychiatric symptoms.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1. Badre N et al. “Coercion and the critical psychiatrist.” In Critical Psychiatry. Springer, Cham, 2019. doi: 10.1007/97-3-030-02732-2_7.

2. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7)784-6.

3. Myrick JG and Willoughby JF. Health Commun. 2021 Jan 14;1-9.

If you are a psychiatrist who has done a public lecture in the past year, you likely encountered the question, “What about Britney’s conservatorship?” Many psychiatrists are far removed from conservatorship evaluations, doing the different yet still important work of alleviating mental suffering without paddling in the controversial waters of involuntary treatment. Others judiciously hide behind the veil of the prudent Goldwater Rule in avoiding such discussions altogether. Regardless of whether psychiatry attempts to stay out of such affairs publicly, our field remains intimately involved in the process itself. This can lead to negative views of psychiatry among the public – that of a medical specialty with ulterior motives operating at the behest of the state.

Some psychiatrists simplistically advocate against any form of involuntary treatment.¹ In many ways, this may appear noble. However, the reality of mental illness, with its potential harm to self and others, introduces the potential for dire consequences of such a position. If society is unwilling to accept behavior that may lead to harm, but psychiatry is unwilling to intervene, then other avenues of restricting such behavior will emerge. Those avenues traditionally have included conscription of law enforcement and the incarceration of patients with mental illness.

Yet, therein lies the conundrum of Ms. Spears and other celebrities on conservatorship. At face value, they do not appear to require conservatorship. We do not think it violates the Goldwater Rule to render this observation. In fact, it may reassure the public if the American Psychiatric Association, as well as individual psychiatrists, were more open about the goal, intent, and limitations of conservatorships.

The process of establishing conservatorships is not driven solely by mental health professionals. Rather, conservatorship laws permit society to enact, through psychiatrists, its desire to alleviate behaviors considered unacceptable in the context of mental illness.

In California, it has resulted in our famous or infamous “5150,” which asks psychiatrists to comment on the danger to self, danger to others, and grave disability of our patients. It can be helpful to frame these criteria regarding the relationship between society and our patients. The criteria of danger to self represents society’s wish to intervene in cases of patients with imminent intent of self-harm, operating under the presumption that a suicide can be prevented. Danger to others represents the societal angst, at times exaggerated,² about people with mental illness perpetuating homicides, especially when off their medication. Grave disability represents public shame at the thought of persons so lost to mental illness they are unable to provide for themselves or even accept food, clothing, and shelter.

While an involuntary hold is necessary at times, working against our patients engenders revolting feelings. We often rationalize involuntary holds as illustrative of sincere compassion for our patients’ suffering and an attempt to lift them out of such tragic conditions. Our patients regularly do not feel our compassion when we are making an argument in a hearing for the restriction of their rights. They see our efforts as an attempt to lock them away “for their own good” because of society’s discomfort with homelessness. As such, we wonder whether our role becomes one of doctors for society, prescribing a treatment for the emotional distress of the community, and at times for ourselves, rather than that of the patient.

One may be perplexed as to how a celebrity could be considered gravely disabled. Celebrities generally have enough income to afford food, clothing, and shelter. One could justifiably ask why an individual with no history of violence would be considered a danger to others. Similarly, one may wonder how, in the absence of any reported attempts to engage in self-harm, with no visible marks of self-harm, someone is determined to be a danger to himself or herself. The bafflement on the part of one on the outside of these determinations can be sharply contrasted by the desperation felt by family members whose loved ones with mental illness appear to meet those criteria yet are consistently turned away by mental health programs and hospitals.

Not uncommonly, it is families advocating for involuntary hospitalization – while lamenting our strict criteria – that prevent doctors from intervening until some tragic fate befalls their loved ones. They criticize what they consider to be too-stringent mental health laws and are infuriated by seemingly obtuse insurance policies limiting care to patients. Most of our colleagues working with those who have severe mental illness share the frustration of these families over the scarcity of psychiatry beds. Therefore, it is particularly shocking when the most mediatized story about conservatorship is not about how hard it is to obtain. The story is about a singer who was seemingly safe, caring for herself, and yet still ended up on a conservatorship.

We wonder whether there is a question of magnitude. Are homeless patients more difficult to place on conservatorship because society sees a lesser stake? One could argue that Ms. Spears and other celebrities would have so much to lose in a single episode of mental illness. A week with mania or psychosis could cause irreparable damage to their persona, opportunity for employment, and their fortune. On the contrary, many of our patients on conservatorship have little to their names, and no one keeping up on their reputation. Triers of facts should ask themselves about the nature of their motivations. Envy, a desire to live vicariously through celebrities, or even less ethical motivations – such as a desire to control and exert authority over those individuals – can influence our decisions.

Throughout the past year, when asked about Ms. Spears, we have pointed out the obvious – she seemingly has a life incompatible with meeting criteria for a psychiatric conservatorship. We have outlined the role, history, and limitations of psychiatric conservatorship. We have shared how such cases are often approached, when required for our own patients or when asked by the court to do so. We have discussed the significant oversight of the system, including the public conservator’s office, which frequently refuses petitions outright. There are hearing officers, who, in the early stages of this process, weigh our case against that of the patients, aided by passionately driven patient advocates. There is the public defender’s office, which, at least in San Diego, vigorously defends the rights of those with mental illness. Most importantly, there are judges who adjudicate those cases with diligence and humility.

As the story has continued to be in the news, we have had numerous conversations about Ms. Spears’ conservatorship with colleagues sharing strong opinions on her case. Many of these colleagues do not have forensic practices and we inevitably find ourselves responding along the lines of, “It is easy to say this, but quite a different thing to prove it in court.” It is hard not to imagine testifying in such a high-profile conservatorship case; testifying, in front of jurors, about a celebrity who may have engaged in what some considered to be unusual behavior.

Conservatorship laws are not about the minutia or criteria of a specific mental health disorder. Patients do not meet criteria for conservatorship by having a certain number of delusional thoughts or a specific type of hallucination. Patients meet criteria for conservatorship because of state-enacted laws based on social factors – such as danger and self-care – the population wishes to treat, even if against the will of those treated. Under this light, one must recognize that a conservatorship trial is not just about mental illness but about how society wants to care for human beings. Psychiatric illness itself is not grounds for conservatorship. Oftentimes, severely ill patients win a hearing for grave disability by simply accepting a referral for housing, showing up to court clothed, and eating the meals provided at the hospital.

With understanding that these laws pertain specifically to behaviors resulting from mental illness that society finds unacceptable, the narrative of a celebrity conservatorship can be considered differently. The stories of celebrities being used and abused by deleterious beings and deleterious conditions have become a genre. Paul Prenter’s treatment of Freddie Mercury documented in the 2018 movie “Bohemian Rhapsody” and John Reid’s alleged betrayal of Elton John, who was suffering from a substance use disorder, documented in the 2019 movie “Rocketman,” are recent examples, among many.

Imagine yourself, as a juror, deciding on the fate of a celebrity. Would you require them to have lost all property, including the clothing on their backs, before intervening? Consider the next time you hear of a celebrity swindled from his or her fortune in a time of crisis and whether it would have been righteous to prevent it. We personally have, at times, argued for restraint in psychiatry’s desire to have more power. This concern extends not only to our ability to control people, but also our ability to force them into being subjected to psychotropic medications with well-known side effects.

At the same time, we remain cognizant of the magnified impact of adverse outcomes on public figures. John Hinckley Jr. did not attempt to murder a bystander; he attempted to kill the president of the United States when he shot at President Ronald Reagan in 1981. That incident led to considerable changes in our laws about insanity. More recently, society was particularly affected by Tom Hanks’ COVID-19 diagnosis. Mr. Hanks’ illness led to scientifically measurable changes in the public’s beliefs regarding the pandemic.³

On the other hand, and of equal importance to the desire to protect public figures from adverse events, is the risk that those same laws intended to protect will harm. From unsanitary asylums to disproportionate placements of minorities on psychiatric holds, we are concerned with unbridled control in the hands of those meant to cure and care. Sadly, there is also a cinematic genre of unprincipled and detrimental mental health treatment, from Brian Wilson’s treatment by his psychologist documented in “Love & Mercy,” to the upcoming “The Shrink Next Door,” featuring a psychiatrist swindling his patient.

With this additional understanding and analysis, we now ask our colleagues what it would take for them to intervene. Would a celebrity losing $100,000,000 because of mental illness constitute a form of grave disability despite remaining dressed? Would a celebrity engaging in significant drug use constitute a form of self-harm despite still recording albums? Would a celebrity failing to fulfill a social commitment to others, including children, constitute a form of harm to others? Those are not trivial questions to answer, and we are glad the Goldwater Rule reminds us of the limitations of speculating on people we do not know.

Nonetheless, the question of conservatorship is more complex than simply saying: “They make money; they have clothes on; this is absurd.” While this may be a catchy, compelling, and relevant argument, when confronted with a more complete narrative, triers of facts may feel compelled to intervene because, in the end, conservatorship laws are about what society is willing to accept rather than an enumeration of psychiatric symptoms.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1. Badre N et al. “Coercion and the critical psychiatrist.” In Critical Psychiatry. Springer, Cham, 2019. doi: 10.1007/97-3-030-02732-2_7.

2. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7)784-6.

3. Myrick JG and Willoughby JF. Health Commun. 2021 Jan 14;1-9.

If you are a psychiatrist who has done a public lecture in the past year, you likely encountered the question, “What about Britney’s conservatorship?” Many psychiatrists are far removed from conservatorship evaluations, doing the different yet still important work of alleviating mental suffering without paddling in the controversial waters of involuntary treatment. Others judiciously hide behind the veil of the prudent Goldwater Rule in avoiding such discussions altogether. Regardless of whether psychiatry attempts to stay out of such affairs publicly, our field remains intimately involved in the process itself. This can lead to negative views of psychiatry among the public – that of a medical specialty with ulterior motives operating at the behest of the state.

Some psychiatrists simplistically advocate against any form of involuntary treatment.¹ In many ways, this may appear noble. However, the reality of mental illness, with its potential harm to self and others, introduces the potential for dire consequences of such a position. If society is unwilling to accept behavior that may lead to harm, but psychiatry is unwilling to intervene, then other avenues of restricting such behavior will emerge. Those avenues traditionally have included conscription of law enforcement and the incarceration of patients with mental illness.

Yet, therein lies the conundrum of Ms. Spears and other celebrities on conservatorship. At face value, they do not appear to require conservatorship. We do not think it violates the Goldwater Rule to render this observation. In fact, it may reassure the public if the American Psychiatric Association, as well as individual psychiatrists, were more open about the goal, intent, and limitations of conservatorships.

The process of establishing conservatorships is not driven solely by mental health professionals. Rather, conservatorship laws permit society to enact, through psychiatrists, its desire to alleviate behaviors considered unacceptable in the context of mental illness.

In California, it has resulted in our famous or infamous “5150,” which asks psychiatrists to comment on the danger to self, danger to others, and grave disability of our patients. It can be helpful to frame these criteria regarding the relationship between society and our patients. The criteria of danger to self represents society’s wish to intervene in cases of patients with imminent intent of self-harm, operating under the presumption that a suicide can be prevented. Danger to others represents the societal angst, at times exaggerated,² about people with mental illness perpetuating homicides, especially when off their medication. Grave disability represents public shame at the thought of persons so lost to mental illness they are unable to provide for themselves or even accept food, clothing, and shelter.

While an involuntary hold is necessary at times, working against our patients engenders revolting feelings. We often rationalize involuntary holds as illustrative of sincere compassion for our patients’ suffering and an attempt to lift them out of such tragic conditions. Our patients regularly do not feel our compassion when we are making an argument in a hearing for the restriction of their rights. They see our efforts as an attempt to lock them away “for their own good” because of society’s discomfort with homelessness. As such, we wonder whether our role becomes one of doctors for society, prescribing a treatment for the emotional distress of the community, and at times for ourselves, rather than that of the patient.

One may be perplexed as to how a celebrity could be considered gravely disabled. Celebrities generally have enough income to afford food, clothing, and shelter. One could justifiably ask why an individual with no history of violence would be considered a danger to others. Similarly, one may wonder how, in the absence of any reported attempts to engage in self-harm, with no visible marks of self-harm, someone is determined to be a danger to himself or herself. The bafflement on the part of one on the outside of these determinations can be sharply contrasted by the desperation felt by family members whose loved ones with mental illness appear to meet those criteria yet are consistently turned away by mental health programs and hospitals.

Not uncommonly, it is families advocating for involuntary hospitalization – while lamenting our strict criteria – that prevent doctors from intervening until some tragic fate befalls their loved ones. They criticize what they consider to be too-stringent mental health laws and are infuriated by seemingly obtuse insurance policies limiting care to patients. Most of our colleagues working with those who have severe mental illness share the frustration of these families over the scarcity of psychiatry beds. Therefore, it is particularly shocking when the most mediatized story about conservatorship is not about how hard it is to obtain. The story is about a singer who was seemingly safe, caring for herself, and yet still ended up on a conservatorship.

We wonder whether there is a question of magnitude. Are homeless patients more difficult to place on conservatorship because society sees a lesser stake? One could argue that Ms. Spears and other celebrities would have so much to lose in a single episode of mental illness. A week with mania or psychosis could cause irreparable damage to their persona, opportunity for employment, and their fortune. On the contrary, many of our patients on conservatorship have little to their names, and no one keeping up on their reputation. Triers of facts should ask themselves about the nature of their motivations. Envy, a desire to live vicariously through celebrities, or even less ethical motivations – such as a desire to control and exert authority over those individuals – can influence our decisions.

Throughout the past year, when asked about Ms. Spears, we have pointed out the obvious – she seemingly has a life incompatible with meeting criteria for a psychiatric conservatorship. We have outlined the role, history, and limitations of psychiatric conservatorship. We have shared how such cases are often approached, when required for our own patients or when asked by the court to do so. We have discussed the significant oversight of the system, including the public conservator’s office, which frequently refuses petitions outright. There are hearing officers, who, in the early stages of this process, weigh our case against that of the patients, aided by passionately driven patient advocates. There is the public defender’s office, which, at least in San Diego, vigorously defends the rights of those with mental illness. Most importantly, there are judges who adjudicate those cases with diligence and humility.

As the story has continued to be in the news, we have had numerous conversations about Ms. Spears’ conservatorship with colleagues sharing strong opinions on her case. Many of these colleagues do not have forensic practices and we inevitably find ourselves responding along the lines of, “It is easy to say this, but quite a different thing to prove it in court.” It is hard not to imagine testifying in such a high-profile conservatorship case; testifying, in front of jurors, about a celebrity who may have engaged in what some considered to be unusual behavior.

Conservatorship laws are not about the minutia or criteria of a specific mental health disorder. Patients do not meet criteria for conservatorship by having a certain number of delusional thoughts or a specific type of hallucination. Patients meet criteria for conservatorship because of state-enacted laws based on social factors – such as danger and self-care – the population wishes to treat, even if against the will of those treated. Under this light, one must recognize that a conservatorship trial is not just about mental illness but about how society wants to care for human beings. Psychiatric illness itself is not grounds for conservatorship. Oftentimes, severely ill patients win a hearing for grave disability by simply accepting a referral for housing, showing up to court clothed, and eating the meals provided at the hospital.

With understanding that these laws pertain specifically to behaviors resulting from mental illness that society finds unacceptable, the narrative of a celebrity conservatorship can be considered differently. The stories of celebrities being used and abused by deleterious beings and deleterious conditions have become a genre. Paul Prenter’s treatment of Freddie Mercury documented in the 2018 movie “Bohemian Rhapsody” and John Reid’s alleged betrayal of Elton John, who was suffering from a substance use disorder, documented in the 2019 movie “Rocketman,” are recent examples, among many.

Imagine yourself, as a juror, deciding on the fate of a celebrity. Would you require them to have lost all property, including the clothing on their backs, before intervening? Consider the next time you hear of a celebrity swindled from his or her fortune in a time of crisis and whether it would have been righteous to prevent it. We personally have, at times, argued for restraint in psychiatry’s desire to have more power. This concern extends not only to our ability to control people, but also our ability to force them into being subjected to psychotropic medications with well-known side effects.

At the same time, we remain cognizant of the magnified impact of adverse outcomes on public figures. John Hinckley Jr. did not attempt to murder a bystander; he attempted to kill the president of the United States when he shot at President Ronald Reagan in 1981. That incident led to considerable changes in our laws about insanity. More recently, society was particularly affected by Tom Hanks’ COVID-19 diagnosis. Mr. Hanks’ illness led to scientifically measurable changes in the public’s beliefs regarding the pandemic.³

On the other hand, and of equal importance to the desire to protect public figures from adverse events, is the risk that those same laws intended to protect will harm. From unsanitary asylums to disproportionate placements of minorities on psychiatric holds, we are concerned with unbridled control in the hands of those meant to cure and care. Sadly, there is also a cinematic genre of unprincipled and detrimental mental health treatment, from Brian Wilson’s treatment by his psychologist documented in “Love & Mercy,” to the upcoming “The Shrink Next Door,” featuring a psychiatrist swindling his patient.

With this additional understanding and analysis, we now ask our colleagues what it would take for them to intervene. Would a celebrity losing $100,000,000 because of mental illness constitute a form of grave disability despite remaining dressed? Would a celebrity engaging in significant drug use constitute a form of self-harm despite still recording albums? Would a celebrity failing to fulfill a social commitment to others, including children, constitute a form of harm to others? Those are not trivial questions to answer, and we are glad the Goldwater Rule reminds us of the limitations of speculating on people we do not know.

Nonetheless, the question of conservatorship is more complex than simply saying: “They make money; they have clothes on; this is absurd.” While this may be a catchy, compelling, and relevant argument, when confronted with a more complete narrative, triers of facts may feel compelled to intervene because, in the end, conservatorship laws are about what society is willing to accept rather than an enumeration of psychiatric symptoms.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1. Badre N et al. “Coercion and the critical psychiatrist.” In Critical Psychiatry. Springer, Cham, 2019. doi: 10.1007/97-3-030-02732-2_7.

2. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7)784-6.

3. Myrick JG and Willoughby JF. Health Commun. 2021 Jan 14;1-9.

LAS VEGAS – Over the course of the COVID-19 pandemic, alcohol-related liver disease has increased in severity, a finding that is likely related to higher consumption of alcohol and reduced care. The difference was notable in higher Model for End-Stage Liver Disease–sodium (MELD-Na) scores, more signs of hepatic decompensation, and higher mortality rates.

“Alcohol consumption during the COVID-19 pandemic led to increased morbidity and mortality, specifically in patients that already had underlying liver disease. The importance of alcohol cessation, counseling, and close physician monitoring is emphasized, given continued or relapsed alcohol consumption can significantly affect quality of life, life expectancy, and liver transplantation candidacy,” research team member Lindsay A. Sobotka, DO, said in an interview. Dr. Sobotka is an assistant professor of gastroenterology, hepatology, and nutrition at the Ohio State University Wexner Medical Center, Columbus.

The research was presented by Ayushi Jain, MD, at the annual meeting of the American College of Gastroenterology. Dr. Jain is a resident at the Ohio State University Wexner Medical Center.

Dr. Jain noted that alcohol sales have gone up during the pandemic, with monthly sales up 14%-44% between February and September 2020, compared with the same months in previous years.
 

Decompensation rates rose

The researchers analyzed data from patients with alcoholic cirrhosis or alcoholic hepatitis who were seen at the Ohio State University Medical Center between March and August 2019, and between March and August 2020.

alenkadr/Thinkstock

During the pandemic, the number of hospital admissions nearly doubled among alcoholic hepatitis patients (86 to 162), but declined slightly among patients with alcoholic cirrhosis (613 to 528), possibly because of efforts to manage decompensation and avoid hospitalizations during the pandemic, according to Dr. Jain. In total, 4 of 162 patients with alcoholic hepatitis and 14 of 528 patients with alcoholic cirrhosis had COVID-19 at the time of admission.

Higher mortality rates were seen during the pandemic, although this was only significant for alcoholic cirrhosis: 14.8% versus 7% for alcoholic hepatitis (P = .06) and 13.5% versus 7.4% for alcoholic cirrhosis (P = .001).

Among those with alcoholic hepatitis, there was no significant change in median Maddrey’s Discriminant Function during the pandemic (P = .51), but the researchers noted a significant decrease in steroid use, from 27 patients to 23 (P = .001). “This may be due to a statistically significant increase in GI bleeds and renal dysfunction that we noted during the pandemic,” said Dr. Jain.

Hepatic decompensation and critical care needs increased among patients admitted with alcoholic hepatitis, including hepatic encephalopathy (P = .037), gastrointestinal bleeding (P = .01), a need for increased oxygen (P = .024), vasopressor support (P = .005), and initiation of hemodialysis (P = .007). The median highest MELD-Na score during admission was also higher during the pandemic (24 vs. 23, P = .04).

Patients with alcoholic cirrhosis had greater decompensation as measured by ascites (P = .01), therapeutic paracentesis (P = .04), titration of diuretics (P = .005), acute kidney injury (P = .005), hepatorenal syndrome (P = .002), and spontaneous bacterial peritonitis (P = .04). They also had greater need for vasopressor support (9% to 14%; P = .006), were more likely to initiate hemodialysis (7% to 11%; P = .015), and had greater mortality (7% to 14%; P = .001).

In all, 212 patients reported increased alcohol intake, 161 reported little change over the past year, and 253 said they were abstinent. MELD-Na scores were highest in the increased group (27), compared with the unchanged group (24) and abstinent group (23) (P = .001).
 

More robust support needed

“This highlights that the increase in alcohol use seems to be associated with higher rates of more severe alcoholic hepatitis, and we are going to need to all be aware of and intervene in these individuals, and try to not only make health care more accessible, but help those with alcohol use disorder to reengage in some support systems [and] harm-reduction measures, to try to reduce the number of these episodes of admissions with severe alcoholic hepatitis,” said Paul Kwo, MD, who comoderated the session. Dr. Kwo is a professor of medicine at Stanford (Calif.) University.

Dr. Kwo suggested that the pandemic has presented dual challenges to patients with alcohol-related liver disease. One is that hospitals have filled up because of an influx of COVID-19 cases, which makes it hard for them to compete for limited resources. The other is that lockdowns and social interruptions may have interfered with the support systems that normally help them to keep sober and maintain health care. “The pandemic really disrupted everybody’s ecosystem substantially, and some of these individuals, as their ecosystems crumble, they don’t have other resources to engage in care, and then they present with far more advanced comorbidities than we might have seen prior to the pandemic,” said Dr. Kwo.

The findings underscore at least one lesson that can be drawn from the pandemic. “We now know that we have to develop more robust systems to provide support for all of these individuals,” said Dr. Kwo.

Comoderator Patricia D. Jones, MD, agreed, and expressed optimism. “We were forced develop more remote or virtual networks, so I think there are a lot of people that are taking advantage maybe of virtual [Alcoholics Anonymous], and that wasn’t something that they necessarily did [before the pandemic]. And so at least we’ve developed some parallel systems that hopefully people will benefit from,” said Dr. Jones, who is an assistant professor of medicine at the University of Miami.

She suggested that physicians should make inquiries about patients with alcohol-related liver disease and their social situations, and might consider trying to connect them to a social worker if called for. “I think that really speaking to the person about where they are would be beneficial,” said Dr. Jones.

Dr. Sobotka, Dr. Jain, Dr. Kwo, and Dr. Jones have no relevant financial disclosures.

LAS VEGAS – Over the course of the COVID-19 pandemic, alcohol-related liver disease has increased in severity, a finding that is likely related to higher consumption of alcohol and reduced care. The difference was notable in higher Model for End-Stage Liver Disease–sodium (MELD-Na) scores, more signs of hepatic decompensation, and higher mortality rates.

“Alcohol consumption during the COVID-19 pandemic led to increased morbidity and mortality, specifically in patients that already had underlying liver disease. The importance of alcohol cessation, counseling, and close physician monitoring is emphasized, given continued or relapsed alcohol consumption can significantly affect quality of life, life expectancy, and liver transplantation candidacy,” research team member Lindsay A. Sobotka, DO, said in an interview. Dr. Sobotka is an assistant professor of gastroenterology, hepatology, and nutrition at the Ohio State University Wexner Medical Center, Columbus.

The research was presented by Ayushi Jain, MD, at the annual meeting of the American College of Gastroenterology. Dr. Jain is a resident at the Ohio State University Wexner Medical Center.

Dr. Jain noted that alcohol sales have gone up during the pandemic, with monthly sales up 14%-44% between February and September 2020, compared with the same months in previous years.
 

Decompensation rates rose

The researchers analyzed data from patients with alcoholic cirrhosis or alcoholic hepatitis who were seen at the Ohio State University Medical Center between March and August 2019, and between March and August 2020.

alenkadr/Thinkstock

During the pandemic, the number of hospital admissions nearly doubled among alcoholic hepatitis patients (86 to 162), but declined slightly among patients with alcoholic cirrhosis (613 to 528), possibly because of efforts to manage decompensation and avoid hospitalizations during the pandemic, according to Dr. Jain. In total, 4 of 162 patients with alcoholic hepatitis and 14 of 528 patients with alcoholic cirrhosis had COVID-19 at the time of admission.

Higher mortality rates were seen during the pandemic, although this was only significant for alcoholic cirrhosis: 14.8% versus 7% for alcoholic hepatitis (P = .06) and 13.5% versus 7.4% for alcoholic cirrhosis (P = .001).

Among those with alcoholic hepatitis, there was no significant change in median Maddrey’s Discriminant Function during the pandemic (P = .51), but the researchers noted a significant decrease in steroid use, from 27 patients to 23 (P = .001). “This may be due to a statistically significant increase in GI bleeds and renal dysfunction that we noted during the pandemic,” said Dr. Jain.

Hepatic decompensation and critical care needs increased among patients admitted with alcoholic hepatitis, including hepatic encephalopathy (P = .037), gastrointestinal bleeding (P = .01), a need for increased oxygen (P = .024), vasopressor support (P = .005), and initiation of hemodialysis (P = .007). The median highest MELD-Na score during admission was also higher during the pandemic (24 vs. 23, P = .04).

Patients with alcoholic cirrhosis had greater decompensation as measured by ascites (P = .01), therapeutic paracentesis (P = .04), titration of diuretics (P = .005), acute kidney injury (P = .005), hepatorenal syndrome (P = .002), and spontaneous bacterial peritonitis (P = .04). They also had greater need for vasopressor support (9% to 14%; P = .006), were more likely to initiate hemodialysis (7% to 11%; P = .015), and had greater mortality (7% to 14%; P = .001).

In all, 212 patients reported increased alcohol intake, 161 reported little change over the past year, and 253 said they were abstinent. MELD-Na scores were highest in the increased group (27), compared with the unchanged group (24) and abstinent group (23) (P = .001).
 

More robust support needed

“This highlights that the increase in alcohol use seems to be associated with higher rates of more severe alcoholic hepatitis, and we are going to need to all be aware of and intervene in these individuals, and try to not only make health care more accessible, but help those with alcohol use disorder to reengage in some support systems [and] harm-reduction measures, to try to reduce the number of these episodes of admissions with severe alcoholic hepatitis,” said Paul Kwo, MD, who comoderated the session. Dr. Kwo is a professor of medicine at Stanford (Calif.) University.

Dr. Kwo suggested that the pandemic has presented dual challenges to patients with alcohol-related liver disease. One is that hospitals have filled up because of an influx of COVID-19 cases, which makes it hard for them to compete for limited resources. The other is that lockdowns and social interruptions may have interfered with the support systems that normally help them to keep sober and maintain health care. “The pandemic really disrupted everybody’s ecosystem substantially, and some of these individuals, as their ecosystems crumble, they don’t have other resources to engage in care, and then they present with far more advanced comorbidities than we might have seen prior to the pandemic,” said Dr. Kwo.

The findings underscore at least one lesson that can be drawn from the pandemic. “We now know that we have to develop more robust systems to provide support for all of these individuals,” said Dr. Kwo.

Comoderator Patricia D. Jones, MD, agreed, and expressed optimism. “We were forced develop more remote or virtual networks, so I think there are a lot of people that are taking advantage maybe of virtual [Alcoholics Anonymous], and that wasn’t something that they necessarily did [before the pandemic]. And so at least we’ve developed some parallel systems that hopefully people will benefit from,” said Dr. Jones, who is an assistant professor of medicine at the University of Miami.

She suggested that physicians should make inquiries about patients with alcohol-related liver disease and their social situations, and might consider trying to connect them to a social worker if called for. “I think that really speaking to the person about where they are would be beneficial,” said Dr. Jones.

Dr. Sobotka, Dr. Jain, Dr. Kwo, and Dr. Jones have no relevant financial disclosures.

LAS VEGAS – Over the course of the COVID-19 pandemic, alcohol-related liver disease has increased in severity, a finding that is likely related to higher consumption of alcohol and reduced care. The difference was notable in higher Model for End-Stage Liver Disease–sodium (MELD-Na) scores, more signs of hepatic decompensation, and higher mortality rates.

“Alcohol consumption during the COVID-19 pandemic led to increased morbidity and mortality, specifically in patients that already had underlying liver disease. The importance of alcohol cessation, counseling, and close physician monitoring is emphasized, given continued or relapsed alcohol consumption can significantly affect quality of life, life expectancy, and liver transplantation candidacy,” research team member Lindsay A. Sobotka, DO, said in an interview. Dr. Sobotka is an assistant professor of gastroenterology, hepatology, and nutrition at the Ohio State University Wexner Medical Center, Columbus.

The research was presented by Ayushi Jain, MD, at the annual meeting of the American College of Gastroenterology. Dr. Jain is a resident at the Ohio State University Wexner Medical Center.

Dr. Jain noted that alcohol sales have gone up during the pandemic, with monthly sales up 14%-44% between February and September 2020, compared with the same months in previous years.
 

Decompensation rates rose

The researchers analyzed data from patients with alcoholic cirrhosis or alcoholic hepatitis who were seen at the Ohio State University Medical Center between March and August 2019, and between March and August 2020.

alenkadr/Thinkstock

During the pandemic, the number of hospital admissions nearly doubled among alcoholic hepatitis patients (86 to 162), but declined slightly among patients with alcoholic cirrhosis (613 to 528), possibly because of efforts to manage decompensation and avoid hospitalizations during the pandemic, according to Dr. Jain. In total, 4 of 162 patients with alcoholic hepatitis and 14 of 528 patients with alcoholic cirrhosis had COVID-19 at the time of admission.

Higher mortality rates were seen during the pandemic, although this was only significant for alcoholic cirrhosis: 14.8% versus 7% for alcoholic hepatitis (P = .06) and 13.5% versus 7.4% for alcoholic cirrhosis (P = .001).

Among those with alcoholic hepatitis, there was no significant change in median Maddrey’s Discriminant Function during the pandemic (P = .51), but the researchers noted a significant decrease in steroid use, from 27 patients to 23 (P = .001). “This may be due to a statistically significant increase in GI bleeds and renal dysfunction that we noted during the pandemic,” said Dr. Jain.

Hepatic decompensation and critical care needs increased among patients admitted with alcoholic hepatitis, including hepatic encephalopathy (P = .037), gastrointestinal bleeding (P = .01), a need for increased oxygen (P = .024), vasopressor support (P = .005), and initiation of hemodialysis (P = .007). The median highest MELD-Na score during admission was also higher during the pandemic (24 vs. 23, P = .04).

Patients with alcoholic cirrhosis had greater decompensation as measured by ascites (P = .01), therapeutic paracentesis (P = .04), titration of diuretics (P = .005), acute kidney injury (P = .005), hepatorenal syndrome (P = .002), and spontaneous bacterial peritonitis (P = .04). They also had greater need for vasopressor support (9% to 14%; P = .006), were more likely to initiate hemodialysis (7% to 11%; P = .015), and had greater mortality (7% to 14%; P = .001).

In all, 212 patients reported increased alcohol intake, 161 reported little change over the past year, and 253 said they were abstinent. MELD-Na scores were highest in the increased group (27), compared with the unchanged group (24) and abstinent group (23) (P = .001).
 

More robust support needed

“This highlights that the increase in alcohol use seems to be associated with higher rates of more severe alcoholic hepatitis, and we are going to need to all be aware of and intervene in these individuals, and try to not only make health care more accessible, but help those with alcohol use disorder to reengage in some support systems [and] harm-reduction measures, to try to reduce the number of these episodes of admissions with severe alcoholic hepatitis,” said Paul Kwo, MD, who comoderated the session. Dr. Kwo is a professor of medicine at Stanford (Calif.) University.

Dr. Kwo suggested that the pandemic has presented dual challenges to patients with alcohol-related liver disease. One is that hospitals have filled up because of an influx of COVID-19 cases, which makes it hard for them to compete for limited resources. The other is that lockdowns and social interruptions may have interfered with the support systems that normally help them to keep sober and maintain health care. “The pandemic really disrupted everybody’s ecosystem substantially, and some of these individuals, as their ecosystems crumble, they don’t have other resources to engage in care, and then they present with far more advanced comorbidities than we might have seen prior to the pandemic,” said Dr. Kwo.

The findings underscore at least one lesson that can be drawn from the pandemic. “We now know that we have to develop more robust systems to provide support for all of these individuals,” said Dr. Kwo.

Comoderator Patricia D. Jones, MD, agreed, and expressed optimism. “We were forced develop more remote or virtual networks, so I think there are a lot of people that are taking advantage maybe of virtual [Alcoholics Anonymous], and that wasn’t something that they necessarily did [before the pandemic]. And so at least we’ve developed some parallel systems that hopefully people will benefit from,” said Dr. Jones, who is an assistant professor of medicine at the University of Miami.

She suggested that physicians should make inquiries about patients with alcohol-related liver disease and their social situations, and might consider trying to connect them to a social worker if called for. “I think that really speaking to the person about where they are would be beneficial,” said Dr. Jones.

Dr. Sobotka, Dr. Jain, Dr. Kwo, and Dr. Jones have no relevant financial disclosures.

Mirroring the opioid crisis, maternal and newborn hepatitis C infections (HCV) more than doubled in the United States between 2009 and 2019, with disproportionate increases in people of White, American Indian, and Alaska Native race, especially those with less education, according to a cross-sectional study published in JAMA Health Forum. However, the level of risk within these populations was mitigated in counties with higher employment, reported Stephen W. Patrick, MD, of Vanderbilt University, in Nashville, Tenn., and coauthors.

“As we develop public health approaches to prevent HCV infections, connect to treatment, and monitor exposed infants, understanding these factors can be of critical importance to tailoring interventions,” Dr. Patrick said in an interview. “HCV is one more complication of the opioid crisis,” he added. “These data also enable us to step back a bit from HCV and look at the landscape of how the opioid crisis continues to grow in complexity and scope. Throughout the opioid crisis we have often failed to recognize and address the unique needs of pregnant people and infants.”

The study authors used data from the National Center for Health Statistics at the Centers for Disease Control and Prevention, and from the Area Health Resource File to examine maternal-infant HCV infection among all U.S. births between 2009 and 2019. The researchers also examined community-level risk factors including rurality, employment, and access to medical care.

In counties reporting HCV, there were 39,380,122 people who had live births, of whom 138,343 (0.4%) were diagnosed with HCV. The overall rate of maternal HCV infection increased from 1.8 to 5.1 per 1,000 live births between 2009 and 2019.

Infection rates were highest in American Indian/Alaska Native (AI/AN) and White people (adjusted odds ratio [aOR] 7.94 and 7.37, respectively) compared with Black people. They were higher among individuals without a 4-year degree compared to those with higher education (aOR, 3.19).

Among these groups considered to be at higher risk for HCV infection, high employment rates somewhat mitigated the risk. Specifically, in counties in the 10th percentile of employment, the predicted probability of HCV increased from 0.16% to 1.37%, between 2009 and 2019, whereas in counties at the 90th percentile of employment, the predicted probability remained similar, at 0.36% in 2009 and 0.48% in 2019.

“With constrained national resources, understanding both individual and community-level factors associated with HCV infections in pregnant people could inform strategies to mitigate its spread, such as harm reduction efforts (e.g., syringe service programs), improving access to treatment for [opioid use disorder] or increasing the obstetrical workforce in high-risk communities, HCV testing strategies in pregnant people and people of childbearing age, and treatment with novel antiviral therapies,” wrote the authors.

In the time since the authors began the study, universal HCV screening for every pregnancy has been recommended by a number of groups, including the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine (SMFM). However, Dr. Patrick says even though such recommendations are now adopted, it will be some time before they are fully operational, making knowledge of HCV risk factors important for obstetricians as well as pediatricians and family physicians. “We don’t know how if hospitals and clinicians have started universal screening for HCV and even when it is completely adopted, understanding individual and community-level factors associated with HCV in pregnant people is still of critical importance,” he explained. “In some of our previous work we have found that non-White HCV-exposed infants are less likely to be tested for HCV than are White infants, even after accounting for multiple individual and hospital-level factors. The pattern we are seeing in our research and in research in other groups is one of unequal treatment of pregnant people with substance use disorder in terms of being given evidence-based treatments, being tested for HCV, and even in child welfare outcomes like foster placement. It is important to know these issues are occurring, but we need specific equitable approaches to ensuring optimal outcomes for all families.

Jeffrey A. Kuller, MD, one of the authors of the SMFM’s new recommendations for universal HCV screening in pregnancy, agreed that until universal screening is widely adopted, awareness of maternal HCV risk factors is important, “to better determine who is at highest risk for hep C, barriers to care, and patients to better target.” This information also affects procedure at the time of delivery, added Dr. Kuller, professor of obstetrics and gynecology in the division of maternal-fetal medicine at Duke University, Durham, N.C. “We do not perform C-sections for the presence of hep C,” he told this publication. However, in labor, “we try to avoid internal fetal monitoring when possible, and early artificial rupture of membranes when possible, and avoid the use of routine episiotomy,” he said. “Hep C–positive patients should also be assessed for other sexually transmitted diseases including HIV, syphilis, gonorrhea, chlamydia, and hep B. “Although we do not typically treat hep C pharmacologically during pregnancy, we try to get the patient placed with a hepatologist for long-term management.”

The study has important implications for pediatric patients, added Audrey R. Lloyd, MD, a med-peds infectious disease fellow who is studying HCV in pregnancy at the University of Alabama at Birmingham. “In the setting of maternal HCV viremia, maternal-fetal transmission occurs in around 6% of exposed infants and around 10% if there is maternal HIV-HCV coinfection,” she said in an interview. “With the increasing rates of HCV in pregnant women described by Dr. Patrick et al., HCV infections among infants will also rise. Even when maternal HCV infection is documented, we often do not do a good job screening the infants for infection and linking them to treatment. This new data makes me worried we may see more complications of pediatric HCV infection in the future,” she added. She explained that safe and effective treatments for HCV infection are approved down to 3 years of age, but patients must first be diagnosed to receive treatment. 

From whichever angle you approach it, tackling both the opioid epidemic and HCV infection in pregnancy will inevitably end up helping both parts of the mother-infant dyad, said Dr. Patrick. “Not too long ago I was caring for an opioid-exposed infant at the hospital where I practice who had transferred in from another center hours away. The mother had not been tested for HCV, so I tested the infant for HCV antibodies which were positive. Imagine that, determining a mother is HCV positive by testing the infant. There are so many layers of systems that should be fixed to make this not happen. And what are the chances the mother, after she found out, was able to access treatment for HCV? What about the infant being tested? The systems are just fragmented and we need to do better.”

The study was funded by the National Institute on Drug Abuse of the National Institutes of Health. Neither Dr. Patrick, Dr. Kuller, nor Dr. Lloyd reported any conflicts of interest.

Mirroring the opioid crisis, maternal and newborn hepatitis C infections (HCV) more than doubled in the United States between 2009 and 2019, with disproportionate increases in people of White, American Indian, and Alaska Native race, especially those with less education, according to a cross-sectional study published in JAMA Health Forum. However, the level of risk within these populations was mitigated in counties with higher employment, reported Stephen W. Patrick, MD, of Vanderbilt University, in Nashville, Tenn., and coauthors.

“As we develop public health approaches to prevent HCV infections, connect to treatment, and monitor exposed infants, understanding these factors can be of critical importance to tailoring interventions,” Dr. Patrick said in an interview. “HCV is one more complication of the opioid crisis,” he added. “These data also enable us to step back a bit from HCV and look at the landscape of how the opioid crisis continues to grow in complexity and scope. Throughout the opioid crisis we have often failed to recognize and address the unique needs of pregnant people and infants.”

The study authors used data from the National Center for Health Statistics at the Centers for Disease Control and Prevention, and from the Area Health Resource File to examine maternal-infant HCV infection among all U.S. births between 2009 and 2019. The researchers also examined community-level risk factors including rurality, employment, and access to medical care.

In counties reporting HCV, there were 39,380,122 people who had live births, of whom 138,343 (0.4%) were diagnosed with HCV. The overall rate of maternal HCV infection increased from 1.8 to 5.1 per 1,000 live births between 2009 and 2019.

Infection rates were highest in American Indian/Alaska Native (AI/AN) and White people (adjusted odds ratio [aOR] 7.94 and 7.37, respectively) compared with Black people. They were higher among individuals without a 4-year degree compared to those with higher education (aOR, 3.19).

Among these groups considered to be at higher risk for HCV infection, high employment rates somewhat mitigated the risk. Specifically, in counties in the 10th percentile of employment, the predicted probability of HCV increased from 0.16% to 1.37%, between 2009 and 2019, whereas in counties at the 90th percentile of employment, the predicted probability remained similar, at 0.36% in 2009 and 0.48% in 2019.

“With constrained national resources, understanding both individual and community-level factors associated with HCV infections in pregnant people could inform strategies to mitigate its spread, such as harm reduction efforts (e.g., syringe service programs), improving access to treatment for [opioid use disorder] or increasing the obstetrical workforce in high-risk communities, HCV testing strategies in pregnant people and people of childbearing age, and treatment with novel antiviral therapies,” wrote the authors.

In the time since the authors began the study, universal HCV screening for every pregnancy has been recommended by a number of groups, including the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine (SMFM). However, Dr. Patrick says even though such recommendations are now adopted, it will be some time before they are fully operational, making knowledge of HCV risk factors important for obstetricians as well as pediatricians and family physicians. “We don’t know how if hospitals and clinicians have started universal screening for HCV and even when it is completely adopted, understanding individual and community-level factors associated with HCV in pregnant people is still of critical importance,” he explained. “In some of our previous work we have found that non-White HCV-exposed infants are less likely to be tested for HCV than are White infants, even after accounting for multiple individual and hospital-level factors. The pattern we are seeing in our research and in research in other groups is one of unequal treatment of pregnant people with substance use disorder in terms of being given evidence-based treatments, being tested for HCV, and even in child welfare outcomes like foster placement. It is important to know these issues are occurring, but we need specific equitable approaches to ensuring optimal outcomes for all families.

Jeffrey A. Kuller, MD, one of the authors of the SMFM’s new recommendations for universal HCV screening in pregnancy, agreed that until universal screening is widely adopted, awareness of maternal HCV risk factors is important, “to better determine who is at highest risk for hep C, barriers to care, and patients to better target.” This information also affects procedure at the time of delivery, added Dr. Kuller, professor of obstetrics and gynecology in the division of maternal-fetal medicine at Duke University, Durham, N.C. “We do not perform C-sections for the presence of hep C,” he told this publication. However, in labor, “we try to avoid internal fetal monitoring when possible, and early artificial rupture of membranes when possible, and avoid the use of routine episiotomy,” he said. “Hep C–positive patients should also be assessed for other sexually transmitted diseases including HIV, syphilis, gonorrhea, chlamydia, and hep B. “Although we do not typically treat hep C pharmacologically during pregnancy, we try to get the patient placed with a hepatologist for long-term management.”

The study has important implications for pediatric patients, added Audrey R. Lloyd, MD, a med-peds infectious disease fellow who is studying HCV in pregnancy at the University of Alabama at Birmingham. “In the setting of maternal HCV viremia, maternal-fetal transmission occurs in around 6% of exposed infants and around 10% if there is maternal HIV-HCV coinfection,” she said in an interview. “With the increasing rates of HCV in pregnant women described by Dr. Patrick et al., HCV infections among infants will also rise. Even when maternal HCV infection is documented, we often do not do a good job screening the infants for infection and linking them to treatment. This new data makes me worried we may see more complications of pediatric HCV infection in the future,” she added. She explained that safe and effective treatments for HCV infection are approved down to 3 years of age, but patients must first be diagnosed to receive treatment. 

From whichever angle you approach it, tackling both the opioid epidemic and HCV infection in pregnancy will inevitably end up helping both parts of the mother-infant dyad, said Dr. Patrick. “Not too long ago I was caring for an opioid-exposed infant at the hospital where I practice who had transferred in from another center hours away. The mother had not been tested for HCV, so I tested the infant for HCV antibodies which were positive. Imagine that, determining a mother is HCV positive by testing the infant. There are so many layers of systems that should be fixed to make this not happen. And what are the chances the mother, after she found out, was able to access treatment for HCV? What about the infant being tested? The systems are just fragmented and we need to do better.”

The study was funded by the National Institute on Drug Abuse of the National Institutes of Health. Neither Dr. Patrick, Dr. Kuller, nor Dr. Lloyd reported any conflicts of interest.

Mirroring the opioid crisis, maternal and newborn hepatitis C infections (HCV) more than doubled in the United States between 2009 and 2019, with disproportionate increases in people of White, American Indian, and Alaska Native race, especially those with less education, according to a cross-sectional study published in JAMA Health Forum. However, the level of risk within these populations was mitigated in counties with higher employment, reported Stephen W. Patrick, MD, of Vanderbilt University, in Nashville, Tenn., and coauthors.

“As we develop public health approaches to prevent HCV infections, connect to treatment, and monitor exposed infants, understanding these factors can be of critical importance to tailoring interventions,” Dr. Patrick said in an interview. “HCV is one more complication of the opioid crisis,” he added. “These data also enable us to step back a bit from HCV and look at the landscape of how the opioid crisis continues to grow in complexity and scope. Throughout the opioid crisis we have often failed to recognize and address the unique needs of pregnant people and infants.”

The study authors used data from the National Center for Health Statistics at the Centers for Disease Control and Prevention, and from the Area Health Resource File to examine maternal-infant HCV infection among all U.S. births between 2009 and 2019. The researchers also examined community-level risk factors including rurality, employment, and access to medical care.

In counties reporting HCV, there were 39,380,122 people who had live births, of whom 138,343 (0.4%) were diagnosed with HCV. The overall rate of maternal HCV infection increased from 1.8 to 5.1 per 1,000 live births between 2009 and 2019.

Infection rates were highest in American Indian/Alaska Native (AI/AN) and White people (adjusted odds ratio [aOR] 7.94 and 7.37, respectively) compared with Black people. They were higher among individuals without a 4-year degree compared to those with higher education (aOR, 3.19).

Among these groups considered to be at higher risk for HCV infection, high employment rates somewhat mitigated the risk. Specifically, in counties in the 10th percentile of employment, the predicted probability of HCV increased from 0.16% to 1.37%, between 2009 and 2019, whereas in counties at the 90th percentile of employment, the predicted probability remained similar, at 0.36% in 2009 and 0.48% in 2019.

“With constrained national resources, understanding both individual and community-level factors associated with HCV infections in pregnant people could inform strategies to mitigate its spread, such as harm reduction efforts (e.g., syringe service programs), improving access to treatment for [opioid use disorder] or increasing the obstetrical workforce in high-risk communities, HCV testing strategies in pregnant people and people of childbearing age, and treatment with novel antiviral therapies,” wrote the authors.

In the time since the authors began the study, universal HCV screening for every pregnancy has been recommended by a number of groups, including the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine (SMFM). However, Dr. Patrick says even though such recommendations are now adopted, it will be some time before they are fully operational, making knowledge of HCV risk factors important for obstetricians as well as pediatricians and family physicians. “We don’t know how if hospitals and clinicians have started universal screening for HCV and even when it is completely adopted, understanding individual and community-level factors associated with HCV in pregnant people is still of critical importance,” he explained. “In some of our previous work we have found that non-White HCV-exposed infants are less likely to be tested for HCV than are White infants, even after accounting for multiple individual and hospital-level factors. The pattern we are seeing in our research and in research in other groups is one of unequal treatment of pregnant people with substance use disorder in terms of being given evidence-based treatments, being tested for HCV, and even in child welfare outcomes like foster placement. It is important to know these issues are occurring, but we need specific equitable approaches to ensuring optimal outcomes for all families.

Jeffrey A. Kuller, MD, one of the authors of the SMFM’s new recommendations for universal HCV screening in pregnancy, agreed that until universal screening is widely adopted, awareness of maternal HCV risk factors is important, “to better determine who is at highest risk for hep C, barriers to care, and patients to better target.” This information also affects procedure at the time of delivery, added Dr. Kuller, professor of obstetrics and gynecology in the division of maternal-fetal medicine at Duke University, Durham, N.C. “We do not perform C-sections for the presence of hep C,” he told this publication. However, in labor, “we try to avoid internal fetal monitoring when possible, and early artificial rupture of membranes when possible, and avoid the use of routine episiotomy,” he said. “Hep C–positive patients should also be assessed for other sexually transmitted diseases including HIV, syphilis, gonorrhea, chlamydia, and hep B. “Although we do not typically treat hep C pharmacologically during pregnancy, we try to get the patient placed with a hepatologist for long-term management.”

The study has important implications for pediatric patients, added Audrey R. Lloyd, MD, a med-peds infectious disease fellow who is studying HCV in pregnancy at the University of Alabama at Birmingham. “In the setting of maternal HCV viremia, maternal-fetal transmission occurs in around 6% of exposed infants and around 10% if there is maternal HIV-HCV coinfection,” she said in an interview. “With the increasing rates of HCV in pregnant women described by Dr. Patrick et al., HCV infections among infants will also rise. Even when maternal HCV infection is documented, we often do not do a good job screening the infants for infection and linking them to treatment. This new data makes me worried we may see more complications of pediatric HCV infection in the future,” she added. She explained that safe and effective treatments for HCV infection are approved down to 3 years of age, but patients must first be diagnosed to receive treatment. 

From whichever angle you approach it, tackling both the opioid epidemic and HCV infection in pregnancy will inevitably end up helping both parts of the mother-infant dyad, said Dr. Patrick. “Not too long ago I was caring for an opioid-exposed infant at the hospital where I practice who had transferred in from another center hours away. The mother had not been tested for HCV, so I tested the infant for HCV antibodies which were positive. Imagine that, determining a mother is HCV positive by testing the infant. There are so many layers of systems that should be fixed to make this not happen. And what are the chances the mother, after she found out, was able to access treatment for HCV? What about the infant being tested? The systems are just fragmented and we need to do better.”

The study was funded by the National Institute on Drug Abuse of the National Institutes of Health. Neither Dr. Patrick, Dr. Kuller, nor Dr. Lloyd reported any conflicts of interest.

Fentanyl is now threatening overdoses in patients exposed to essentially any of the full array of recreational drugs – not just opioids – that are being sold illicitly, according to an overview of the problem presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

US DEA

“Fentanyl can now be found in cocaine and methamphetamine. At this point, there is really no way to predict what is in a [street] drug,” Edwin A. Salsitz, MD, said at the meeting, sponsored by Medscape Live. He is associate clinical professor of medicine who works in the division of chemical dependency at Mount Sinai Beth Israel Medical Center in New York.

As proof of the frequency with which fentanyl is now being used as an additive, most patients with a drug use disorder, regardless of their drug of choice, are testing positive for fentanyl at Dr. Salsitz’s center. Many of those with positive fentanyl tests are unaware that their drugs had been doctored with this agent.

Relative to drugs sold as an opioid, such as heroin or oxycodone, the fentanyl dose in nonopioid drugs is typically more modest, but Dr. Salsitz pointed out that those expecting cocaine or methamphetamine often “have no heroin tolerance, so they are more vulnerable” to the adverse effects of fentanyl, including an overdose.

Although opioid tolerance might improve the chances for surviving a fentanyl overdose, the toxicology of fentanyl is not the same as other opioids. Death from heroin is typically a result of respiratory depression, but the onset is relatively slow, providing a greater opportunity to administer a reversal agent, such as naloxone.

Fentanyl not only produces respiratory depression but skeletal muscle rigidity. The rapid onset of “wooden chest syndrome” can occur within minutes, making the opportunity for intervention much smaller, Dr. Salsitz said.

To illustrate the phenomenon, Dr. Salsitz recounted a case.

After an argument with his mother, a 26-year-old male with a long history of intravenous drug use went to his bedroom. His mother, responding to the sound of a loud thud, rushed to the bedroom to find her son on the floor with a needle still in his arm. Resuscitation efforts by the mother and by the emergency responders, who arrived quickly, failed.

“The speed of his death made it clear that it was fentanyl related, and the postmortem toxicology confirmed that the exposure involved both heroin and fentanyl,” Dr. Salsitz said.

After the first wave of deaths in the opioid epidemic, which was attributed to inappropriate use of prescription opioids, the second wave was driven by heroin. In that wave, patients who became addicted to prescription opioids but were having more difficulty gaining access to them, turned to far cheaper and readily available street heroin. The third wave, driven by fentanyl, began several years ago when sellers of heroin began adding this synthetic opioid, which is relatively cheap, to intensify the high.

It is not expected to end quickly. The fentanyl added to heroin was never a prescription version. Rather, Dr. Salsitz said, it is synthesized in laboratories in China, Mexico, and the United States. It is relatively easy to produce and compact, which makes it easy to transport.

Exacerbating the risks that fentanyl poses when added to street drugs, even more potent versions, such as carfentanil, are also being added to cocaine, methamphetamines, and other nonopioid illicit drugs. When compared on a per-milligram basis, fentanyl is about 100 times more potent than heroin, but carfentanil is about 100 times more potent than fentanyl, according to Dr. Salsitz.

When the third wave of deaths in the opioid epidemic began around 2013, prescriptions of fentanyl, like many other opioid-type therapies were declining. The “perfect storm” that initiated the opioid epidemic was a product of intense focus on pain control and a misperception that prescription opioids posed a low risk of abuse potential, Dr. Salsitz said. By the time fentanyl was driving opioid deaths, the risks of opioids were widely appreciated and their use for prescription analgesia was declining.

Citing several cases, Dr. Salsitz noted that only 20 years after clinicians were being successfully sued for not offering enough analgesia, they were now going to jail for prescribing these drugs too liberally.

According to Dr. Salsitz, the pendulum might now have swung too far in the other direction so that at least some patients are no longer receiving adequate pain control. While psychiatrists might not have a role in this issue, Dr. Salsitz did see a role for these specialists in protecting patients from the adverse consequences of using illicit drugs doctored with fentanyl.

Noting that individuals with psychiatric disorders are more likely than the general population to self-medicate with drugs purchased illegally, Dr. Salsitz encouraged psychiatrists “to get involved” in asking about drug use and counseling patients on the risks of fentanyl substitution or additives.

“The message is that no one knows what are in these drugs, anymore,” he said.

In addition to making patients aware that many street drugs are now contaminated with fentanyl, Dr. Salsitz provided some safety tips. He suggested instructing patients to take a low dose of any newly acquired drug to gauge its effect, to avoid taking drugs alone, and to avoid mixing drugs. He also recommended using rapid fentanyl test strips in order to detect fentanyl contamination.

Even for the many psychiatrists who do not feel comfortable managing addiction, Dr. Salsitz recommended a proactive approach to address the current threat.
 

Test strips as an intervention

The seriousness of fentanyl contamination of illicit drugs, including cocaine and methamphetamine, was corroborated by two investigators at the School of Public Health and the Albert Einstein Medical School of Brown University, Providence, R.I. Brandon D.L. Marshall, PhD, associate professor of epidemiology in the School of Public Health, called fentanyl-contaminated cannabis “extremely rare,” but he said that it is being found in counterfeit prescription pills as well as in crystal methamphetamine and in both crack and powder cocaine.

He also advocated the use of fentanyl test strips.

“Test strips are an efficient, inexpensive, and effective way to determine whether fentanyl or related analogs are present in illicit drugs,” he said, noting that he is involved in a trial designed to determine whether fentanyl test strips can reduce the risk of fatal and nonfatal overdoses.

In a pilot study conducted in Baltimore, 69% of the 103 participants engaged in harm reduction behavior after using a fentanyl test strip and receiving a positive result (Addict Behav. 2020;110:106529). It is notable that 86% of the participants had a least one positive result when using the strips. More than half were surprised by the result.

One of the findings from this study was “that the lasting benefit of fentanyl test strip distribution is the opportunity to engage in discussions around safety and relationship building with historically underserved communities,” said the lead author, Ju Nyeong Park, PhD, assistant professor of medicine and epidemiology at Brown University. She moved to Brown after performing this work at Johns Hopkins University, Baltimore.

Dr. Park noted that “many patients in the community already know that they are using drugs containing fentanyl,” but for those who are concerned and wish to avoid contaminated drugs, fentanyl test strips “are a quick screening tool.” However, while the strips are helpful, she cautioned that they cannot be considered a definitive tool for detecting harm in illicit drugs.

“There may also be other chemicals present in tested drugs that confer risk,” she said.

Medscape Live and this news organization are owned by the same parent company. Dr. Salsitz, Dr. Marshall, and Dr. Park reported no potential conflicts of interest.

Fentanyl is now threatening overdoses in patients exposed to essentially any of the full array of recreational drugs – not just opioids – that are being sold illicitly, according to an overview of the problem presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

US DEA

“Fentanyl can now be found in cocaine and methamphetamine. At this point, there is really no way to predict what is in a [street] drug,” Edwin A. Salsitz, MD, said at the meeting, sponsored by Medscape Live. He is associate clinical professor of medicine who works in the division of chemical dependency at Mount Sinai Beth Israel Medical Center in New York.

As proof of the frequency with which fentanyl is now being used as an additive, most patients with a drug use disorder, regardless of their drug of choice, are testing positive for fentanyl at Dr. Salsitz’s center. Many of those with positive fentanyl tests are unaware that their drugs had been doctored with this agent.

Relative to drugs sold as an opioid, such as heroin or oxycodone, the fentanyl dose in nonopioid drugs is typically more modest, but Dr. Salsitz pointed out that those expecting cocaine or methamphetamine often “have no heroin tolerance, so they are more vulnerable” to the adverse effects of fentanyl, including an overdose.

Although opioid tolerance might improve the chances for surviving a fentanyl overdose, the toxicology of fentanyl is not the same as other opioids. Death from heroin is typically a result of respiratory depression, but the onset is relatively slow, providing a greater opportunity to administer a reversal agent, such as naloxone.

Fentanyl not only produces respiratory depression but skeletal muscle rigidity. The rapid onset of “wooden chest syndrome” can occur within minutes, making the opportunity for intervention much smaller, Dr. Salsitz said.

To illustrate the phenomenon, Dr. Salsitz recounted a case.

After an argument with his mother, a 26-year-old male with a long history of intravenous drug use went to his bedroom. His mother, responding to the sound of a loud thud, rushed to the bedroom to find her son on the floor with a needle still in his arm. Resuscitation efforts by the mother and by the emergency responders, who arrived quickly, failed.

“The speed of his death made it clear that it was fentanyl related, and the postmortem toxicology confirmed that the exposure involved both heroin and fentanyl,” Dr. Salsitz said.

After the first wave of deaths in the opioid epidemic, which was attributed to inappropriate use of prescription opioids, the second wave was driven by heroin. In that wave, patients who became addicted to prescription opioids but were having more difficulty gaining access to them, turned to far cheaper and readily available street heroin. The third wave, driven by fentanyl, began several years ago when sellers of heroin began adding this synthetic opioid, which is relatively cheap, to intensify the high.

It is not expected to end quickly. The fentanyl added to heroin was never a prescription version. Rather, Dr. Salsitz said, it is synthesized in laboratories in China, Mexico, and the United States. It is relatively easy to produce and compact, which makes it easy to transport.

Exacerbating the risks that fentanyl poses when added to street drugs, even more potent versions, such as carfentanil, are also being added to cocaine, methamphetamines, and other nonopioid illicit drugs. When compared on a per-milligram basis, fentanyl is about 100 times more potent than heroin, but carfentanil is about 100 times more potent than fentanyl, according to Dr. Salsitz.

When the third wave of deaths in the opioid epidemic began around 2013, prescriptions of fentanyl, like many other opioid-type therapies were declining. The “perfect storm” that initiated the opioid epidemic was a product of intense focus on pain control and a misperception that prescription opioids posed a low risk of abuse potential, Dr. Salsitz said. By the time fentanyl was driving opioid deaths, the risks of opioids were widely appreciated and their use for prescription analgesia was declining.

Citing several cases, Dr. Salsitz noted that only 20 years after clinicians were being successfully sued for not offering enough analgesia, they were now going to jail for prescribing these drugs too liberally.

According to Dr. Salsitz, the pendulum might now have swung too far in the other direction so that at least some patients are no longer receiving adequate pain control. While psychiatrists might not have a role in this issue, Dr. Salsitz did see a role for these specialists in protecting patients from the adverse consequences of using illicit drugs doctored with fentanyl.

Noting that individuals with psychiatric disorders are more likely than the general population to self-medicate with drugs purchased illegally, Dr. Salsitz encouraged psychiatrists “to get involved” in asking about drug use and counseling patients on the risks of fentanyl substitution or additives.

“The message is that no one knows what are in these drugs, anymore,” he said.

In addition to making patients aware that many street drugs are now contaminated with fentanyl, Dr. Salsitz provided some safety tips. He suggested instructing patients to take a low dose of any newly acquired drug to gauge its effect, to avoid taking drugs alone, and to avoid mixing drugs. He also recommended using rapid fentanyl test strips in order to detect fentanyl contamination.

Even for the many psychiatrists who do not feel comfortable managing addiction, Dr. Salsitz recommended a proactive approach to address the current threat.
 

Test strips as an intervention

The seriousness of fentanyl contamination of illicit drugs, including cocaine and methamphetamine, was corroborated by two investigators at the School of Public Health and the Albert Einstein Medical School of Brown University, Providence, R.I. Brandon D.L. Marshall, PhD, associate professor of epidemiology in the School of Public Health, called fentanyl-contaminated cannabis “extremely rare,” but he said that it is being found in counterfeit prescription pills as well as in crystal methamphetamine and in both crack and powder cocaine.

He also advocated the use of fentanyl test strips.

“Test strips are an efficient, inexpensive, and effective way to determine whether fentanyl or related analogs are present in illicit drugs,” he said, noting that he is involved in a trial designed to determine whether fentanyl test strips can reduce the risk of fatal and nonfatal overdoses.

In a pilot study conducted in Baltimore, 69% of the 103 participants engaged in harm reduction behavior after using a fentanyl test strip and receiving a positive result (Addict Behav. 2020;110:106529). It is notable that 86% of the participants had a least one positive result when using the strips. More than half were surprised by the result.

One of the findings from this study was “that the lasting benefit of fentanyl test strip distribution is the opportunity to engage in discussions around safety and relationship building with historically underserved communities,” said the lead author, Ju Nyeong Park, PhD, assistant professor of medicine and epidemiology at Brown University. She moved to Brown after performing this work at Johns Hopkins University, Baltimore.

Dr. Park noted that “many patients in the community already know that they are using drugs containing fentanyl,” but for those who are concerned and wish to avoid contaminated drugs, fentanyl test strips “are a quick screening tool.” However, while the strips are helpful, she cautioned that they cannot be considered a definitive tool for detecting harm in illicit drugs.

“There may also be other chemicals present in tested drugs that confer risk,” she said.

Medscape Live and this news organization are owned by the same parent company. Dr. Salsitz, Dr. Marshall, and Dr. Park reported no potential conflicts of interest.

Fentanyl is now threatening overdoses in patients exposed to essentially any of the full array of recreational drugs – not just opioids – that are being sold illicitly, according to an overview of the problem presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

US DEA

“Fentanyl can now be found in cocaine and methamphetamine. At this point, there is really no way to predict what is in a [street] drug,” Edwin A. Salsitz, MD, said at the meeting, sponsored by Medscape Live. He is associate clinical professor of medicine who works in the division of chemical dependency at Mount Sinai Beth Israel Medical Center in New York.

As proof of the frequency with which fentanyl is now being used as an additive, most patients with a drug use disorder, regardless of their drug of choice, are testing positive for fentanyl at Dr. Salsitz’s center. Many of those with positive fentanyl tests are unaware that their drugs had been doctored with this agent.

Relative to drugs sold as an opioid, such as heroin or oxycodone, the fentanyl dose in nonopioid drugs is typically more modest, but Dr. Salsitz pointed out that those expecting cocaine or methamphetamine often “have no heroin tolerance, so they are more vulnerable” to the adverse effects of fentanyl, including an overdose.

Although opioid tolerance might improve the chances for surviving a fentanyl overdose, the toxicology of fentanyl is not the same as other opioids. Death from heroin is typically a result of respiratory depression, but the onset is relatively slow, providing a greater opportunity to administer a reversal agent, such as naloxone.

Fentanyl not only produces respiratory depression but skeletal muscle rigidity. The rapid onset of “wooden chest syndrome” can occur within minutes, making the opportunity for intervention much smaller, Dr. Salsitz said.

To illustrate the phenomenon, Dr. Salsitz recounted a case.

After an argument with his mother, a 26-year-old male with a long history of intravenous drug use went to his bedroom. His mother, responding to the sound of a loud thud, rushed to the bedroom to find her son on the floor with a needle still in his arm. Resuscitation efforts by the mother and by the emergency responders, who arrived quickly, failed.

“The speed of his death made it clear that it was fentanyl related, and the postmortem toxicology confirmed that the exposure involved both heroin and fentanyl,” Dr. Salsitz said.

After the first wave of deaths in the opioid epidemic, which was attributed to inappropriate use of prescription opioids, the second wave was driven by heroin. In that wave, patients who became addicted to prescription opioids but were having more difficulty gaining access to them, turned to far cheaper and readily available street heroin. The third wave, driven by fentanyl, began several years ago when sellers of heroin began adding this synthetic opioid, which is relatively cheap, to intensify the high.

It is not expected to end quickly. The fentanyl added to heroin was never a prescription version. Rather, Dr. Salsitz said, it is synthesized in laboratories in China, Mexico, and the United States. It is relatively easy to produce and compact, which makes it easy to transport.

Exacerbating the risks that fentanyl poses when added to street drugs, even more potent versions, such as carfentanil, are also being added to cocaine, methamphetamines, and other nonopioid illicit drugs. When compared on a per-milligram basis, fentanyl is about 100 times more potent than heroin, but carfentanil is about 100 times more potent than fentanyl, according to Dr. Salsitz.

When the third wave of deaths in the opioid epidemic began around 2013, prescriptions of fentanyl, like many other opioid-type therapies were declining. The “perfect storm” that initiated the opioid epidemic was a product of intense focus on pain control and a misperception that prescription opioids posed a low risk of abuse potential, Dr. Salsitz said. By the time fentanyl was driving opioid deaths, the risks of opioids were widely appreciated and their use for prescription analgesia was declining.

Citing several cases, Dr. Salsitz noted that only 20 years after clinicians were being successfully sued for not offering enough analgesia, they were now going to jail for prescribing these drugs too liberally.

According to Dr. Salsitz, the pendulum might now have swung too far in the other direction so that at least some patients are no longer receiving adequate pain control. While psychiatrists might not have a role in this issue, Dr. Salsitz did see a role for these specialists in protecting patients from the adverse consequences of using illicit drugs doctored with fentanyl.

Noting that individuals with psychiatric disorders are more likely than the general population to self-medicate with drugs purchased illegally, Dr. Salsitz encouraged psychiatrists “to get involved” in asking about drug use and counseling patients on the risks of fentanyl substitution or additives.

“The message is that no one knows what are in these drugs, anymore,” he said.

In addition to making patients aware that many street drugs are now contaminated with fentanyl, Dr. Salsitz provided some safety tips. He suggested instructing patients to take a low dose of any newly acquired drug to gauge its effect, to avoid taking drugs alone, and to avoid mixing drugs. He also recommended using rapid fentanyl test strips in order to detect fentanyl contamination.

Even for the many psychiatrists who do not feel comfortable managing addiction, Dr. Salsitz recommended a proactive approach to address the current threat.
 

Test strips as an intervention

The seriousness of fentanyl contamination of illicit drugs, including cocaine and methamphetamine, was corroborated by two investigators at the School of Public Health and the Albert Einstein Medical School of Brown University, Providence, R.I. Brandon D.L. Marshall, PhD, associate professor of epidemiology in the School of Public Health, called fentanyl-contaminated cannabis “extremely rare,” but he said that it is being found in counterfeit prescription pills as well as in crystal methamphetamine and in both crack and powder cocaine.

He also advocated the use of fentanyl test strips.

“Test strips are an efficient, inexpensive, and effective way to determine whether fentanyl or related analogs are present in illicit drugs,” he said, noting that he is involved in a trial designed to determine whether fentanyl test strips can reduce the risk of fatal and nonfatal overdoses.

In a pilot study conducted in Baltimore, 69% of the 103 participants engaged in harm reduction behavior after using a fentanyl test strip and receiving a positive result (Addict Behav. 2020;110:106529). It is notable that 86% of the participants had a least one positive result when using the strips. More than half were surprised by the result.

One of the findings from this study was “that the lasting benefit of fentanyl test strip distribution is the opportunity to engage in discussions around safety and relationship building with historically underserved communities,” said the lead author, Ju Nyeong Park, PhD, assistant professor of medicine and epidemiology at Brown University. She moved to Brown after performing this work at Johns Hopkins University, Baltimore.

Dr. Park noted that “many patients in the community already know that they are using drugs containing fentanyl,” but for those who are concerned and wish to avoid contaminated drugs, fentanyl test strips “are a quick screening tool.” However, while the strips are helpful, she cautioned that they cannot be considered a definitive tool for detecting harm in illicit drugs.

“There may also be other chemicals present in tested drugs that confer risk,” she said.

Medscape Live and this news organization are owned by the same parent company. Dr. Salsitz, Dr. Marshall, and Dr. Park reported no potential conflicts of interest.

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

HighGradeRoots/iStock/Getty Images

While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.

Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.

The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
 

Impact of severe CUD ‘incapacitating’

“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.

However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).

This report evaluated the potential risks and benefits on the basis of published studies.

There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.

The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.

In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.

Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
 

More support for cannabis in medical disease

Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.

In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.

While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis. Dr. Martinez indicated that a conservative approach is prudent with the limited evidence available for patients with psychiatric disorders.
 

Empirical evidence for therapeutic role

In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.

“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”

In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.

“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.

Misuse of buprenorphine in the United States by patients with opioid use disorder (OUD) dropped sharply between 2015 and 2019, new research shows.

Analyses of data from the National Survey on Drug Use and Health also showed that about 50% of the patients with OUD were not receiving substance use treatment – and that some may be misusing buprenorphine in an effort to self-treat their addiction.

Interestingly, there was no association between buprenorphine misuse and income among those with OUD or with race, ethnicity, or insurance status regardless of OUD status, which bucks commonly held perceptions of those with the disorder.

Overall, the findings “underscore the need to pursue actions that expand access to buprenorphine-based OUD treatment, to develop strategies to monitor and reduce buprenorphine misuse, and to address associated conditions,” the investigators, led by Beth Han, MD, PhD, National Institute on Drug Abuse (NIDA), write.

The study was published online October 15 in JAMA Network Open.
 

Opioid deaths

Centers for Disease Control and Prevention data show more than 93,000 individuals in the United States died from a drug overdose in 2020, a 29.4% increase from the previous year. Of those deaths, 69,710 involved opioids.

Buprenorphine, a medication approved by the U.S. Food and Drug Administration to treat OUD, has been shown to reduce opioid cravings and withdrawal symptoms and lower overdose risk.

The new survey included responses from 214,505 adults. Of these, 51.7% were women, 45.5% were age 50 years or older, and 63.9% were non-Hispanic White.

Responses were collected between 2015-2019 as part of an annual survey administered annually by the Substance Abuse and Mental Health Services Administration.

Misuse was defined as any use outside the prescribed amount, frequency, duration, or indication.

In 2019, hydrocodone, oxycodone, codeine, and tramadol were the most misused prescription opioid products. An estimated 2.4 million adults used buprenorphine, with 1.7 million reporting no misuse in the past 12 months.

While buprenorphine misuse was stable between 2015 and 2019 among individuals without OUD, misuse declined significantly among those with OUD – from 20.5% in 2015 to 15.9% in 2019 (P = .04).
 

A different picture of misuse

The demographic data reveals a picture of buprenorphine misuse that researchers note is quite different from common perceptions about people with substance use.

Those with OUD who misused buprenorphine were more likely to be non-Hispanic White (82.9% vs. 73.6%, respectively) and less likely to live in large metropolitan areas (47.7% vs. 58.1%).

Among participants with OUD, buprenorphine misuse was significantly associated with age, especially in those between 24 and 34 years (adjusted odds ratio [aOR], 2.9; 95% confidence interval, 1.4-5.8) and between 35 and 49 years (aOR, 2.3; 95% CI, 1.2-4.5).

It was also significantly associated with living in nonmetropolitan areas (aOR, 1.8; 95% CI, 1.0-3.0) and having past-year polysubstance use and use disorders (aOR, 3.9; 95% CI, 1.3-11.2); but negatively associated with past-year treatment for illicit drug use–only treatment (aOR, 0.4; 95% CI, 0.3-0.7).

There was no significant association between buprenorphine misuse and income in participants with OUD or with race, ethnicity, or insurance status, regardless of OUD status.

“Perceptions that persons of racial and ethnic minority groups and people living in poverty are more likely to misuse their medication are incorrect,” the researchers write.

“Nevertheless, these factors have been found to be important factors associated with opioid harms and receipt of buprenorphine treatment,” they add.

Between 2015 and 2017, the largest increase in opioid-related drug overdose deaths was among Black people aged 25 to 34, and the largest increase involving synthetic opioids was among Hispanic individuals aged 45 to 54. At the same time, White people were more likely to receive buprenorphine treatment for OUD.
 

‘Don’t exaggerate concerns’

Among survey participants with OUD, 57% of those who had misused buprenorphine in the past year had received no substance use treatment. Among those with OUD who had not misused the drug in the past year, 49% had received no treatment for their addiction.

The most common reason for buprenorphine misuse cited by those with OUD was “because I am hooked” (27.3%), which researchers said suggests people may be taking buprenorphine without a prescription to self-treat their OUD.

The investigators note that although buprenorphine is inexpensive and effective, clinicians currently must receive a federal waiver to prescribe it to more than 30 patients at a time.

Concern over potential misuse may be one reason some clinicians have been reluctant to complete the training process. However, the study results showed misuse rates of other opioids, including oxycodone and hydrocodone, were higher than those reported for buprenorphine.

“Many other prescription opioids are misused at much higher rates,” co-investigator Wilson Compton, MD, MPE, deputy director of NIDA, told this news organization.

“While there are concerns about all of them, we want to make sure that people don’t exaggerate the concerns – and understanding that oxycodone and hydrocodone are so much more frequently misused is important,” added Dr. Compton.
 

Symptom of inadequate access?

Commenting on the research, Bobby Mukkamala, MD, chair of the American Medical Association Board of Trustees, said individuals who misuse buprenorphine “commonly do so to alleviate uncontrolled pain or symptoms of withdrawal.”

“So-called misuse of buprenorphine is a symptom of inadequate access to physicians to treat opioid use disorder,” said Dr. Mukkamala, who also chairs the AMA Substance Use and Pain Care Task Force.

A 2020 study from the U.S. Department of Health & Human Services showed 40% of U.S. counties have no clinicians with a federal waiver permitting them to prescribe buprenorphine in an office setting.

In April, the HHS released new practice guidelines that allow certain practitioners licensed under state law who have a valid Drug Enforcement Administration registration to treat up to 30 patients with buprenorphine without having to complete requirements related to training, counseling, and other ancillary services known as an “X-waiver.”

The move was welcomed by many in the field, but Dr. Mukkamala said the agency did not go far enough.

“The AMA supports removing the federal X-waiver requirement to help destigmatize the provision of buprenorphine as well as remove the many administrative barriers that come with the federal requirement,” he said.

The study was funded by the National Institute on Drug Abuse. The study authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Misuse of buprenorphine in the United States by patients with opioid use disorder (OUD) dropped sharply between 2015 and 2019, new research shows.

Analyses of data from the National Survey on Drug Use and Health also showed that about 50% of the patients with OUD were not receiving substance use treatment – and that some may be misusing buprenorphine in an effort to self-treat their addiction.

Interestingly, there was no association between buprenorphine misuse and income among those with OUD or with race, ethnicity, or insurance status regardless of OUD status, which bucks commonly held perceptions of those with the disorder.

Overall, the findings “underscore the need to pursue actions that expand access to buprenorphine-based OUD treatment, to develop strategies to monitor and reduce buprenorphine misuse, and to address associated conditions,” the investigators, led by Beth Han, MD, PhD, National Institute on Drug Abuse (NIDA), write.

The study was published online October 15 in JAMA Network Open.
 

Opioid deaths

Centers for Disease Control and Prevention data show more than 93,000 individuals in the United States died from a drug overdose in 2020, a 29.4% increase from the previous year. Of those deaths, 69,710 involved opioids.

Buprenorphine, a medication approved by the U.S. Food and Drug Administration to treat OUD, has been shown to reduce opioid cravings and withdrawal symptoms and lower overdose risk.

The new survey included responses from 214,505 adults. Of these, 51.7% were women, 45.5% were age 50 years or older, and 63.9% were non-Hispanic White.

Responses were collected between 2015-2019 as part of an annual survey administered annually by the Substance Abuse and Mental Health Services Administration.

Misuse was defined as any use outside the prescribed amount, frequency, duration, or indication.

In 2019, hydrocodone, oxycodone, codeine, and tramadol were the most misused prescription opioid products. An estimated 2.4 million adults used buprenorphine, with 1.7 million reporting no misuse in the past 12 months.

While buprenorphine misuse was stable between 2015 and 2019 among individuals without OUD, misuse declined significantly among those with OUD – from 20.5% in 2015 to 15.9% in 2019 (P = .04).
 

A different picture of misuse

The demographic data reveals a picture of buprenorphine misuse that researchers note is quite different from common perceptions about people with substance use.

Those with OUD who misused buprenorphine were more likely to be non-Hispanic White (82.9% vs. 73.6%, respectively) and less likely to live in large metropolitan areas (47.7% vs. 58.1%).

Among participants with OUD, buprenorphine misuse was significantly associated with age, especially in those between 24 and 34 years (adjusted odds ratio [aOR], 2.9; 95% confidence interval, 1.4-5.8) and between 35 and 49 years (aOR, 2.3; 95% CI, 1.2-4.5).

It was also significantly associated with living in nonmetropolitan areas (aOR, 1.8; 95% CI, 1.0-3.0) and having past-year polysubstance use and use disorders (aOR, 3.9; 95% CI, 1.3-11.2); but negatively associated with past-year treatment for illicit drug use–only treatment (aOR, 0.4; 95% CI, 0.3-0.7).

There was no significant association between buprenorphine misuse and income in participants with OUD or with race, ethnicity, or insurance status, regardless of OUD status.

“Perceptions that persons of racial and ethnic minority groups and people living in poverty are more likely to misuse their medication are incorrect,” the researchers write.

“Nevertheless, these factors have been found to be important factors associated with opioid harms and receipt of buprenorphine treatment,” they add.

Between 2015 and 2017, the largest increase in opioid-related drug overdose deaths was among Black people aged 25 to 34, and the largest increase involving synthetic opioids was among Hispanic individuals aged 45 to 54. At the same time, White people were more likely to receive buprenorphine treatment for OUD.
 

‘Don’t exaggerate concerns’

Among survey participants with OUD, 57% of those who had misused buprenorphine in the past year had received no substance use treatment. Among those with OUD who had not misused the drug in the past year, 49% had received no treatment for their addiction.

The most common reason for buprenorphine misuse cited by those with OUD was “because I am hooked” (27.3%), which researchers said suggests people may be taking buprenorphine without a prescription to self-treat their OUD.

The investigators note that although buprenorphine is inexpensive and effective, clinicians currently must receive a federal waiver to prescribe it to more than 30 patients at a time.

Concern over potential misuse may be one reason some clinicians have been reluctant to complete the training process. However, the study results showed misuse rates of other opioids, including oxycodone and hydrocodone, were higher than those reported for buprenorphine.

“Many other prescription opioids are misused at much higher rates,” co-investigator Wilson Compton, MD, MPE, deputy director of NIDA, told this news organization.

“While there are concerns about all of them, we want to make sure that people don’t exaggerate the concerns – and understanding that oxycodone and hydrocodone are so much more frequently misused is important,” added Dr. Compton.
 

Symptom of inadequate access?

Commenting on the research, Bobby Mukkamala, MD, chair of the American Medical Association Board of Trustees, said individuals who misuse buprenorphine “commonly do so to alleviate uncontrolled pain or symptoms of withdrawal.”

“So-called misuse of buprenorphine is a symptom of inadequate access to physicians to treat opioid use disorder,” said Dr. Mukkamala, who also chairs the AMA Substance Use and Pain Care Task Force.

A 2020 study from the U.S. Department of Health & Human Services showed 40% of U.S. counties have no clinicians with a federal waiver permitting them to prescribe buprenorphine in an office setting.

In April, the HHS released new practice guidelines that allow certain practitioners licensed under state law who have a valid Drug Enforcement Administration registration to treat up to 30 patients with buprenorphine without having to complete requirements related to training, counseling, and other ancillary services known as an “X-waiver.”

The move was welcomed by many in the field, but Dr. Mukkamala said the agency did not go far enough.

“The AMA supports removing the federal X-waiver requirement to help destigmatize the provision of buprenorphine as well as remove the many administrative barriers that come with the federal requirement,” he said.

The study was funded by the National Institute on Drug Abuse. The study authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Misuse of buprenorphine in the United States by patients with opioid use disorder (OUD) dropped sharply between 2015 and 2019, new research shows.

Analyses of data from the National Survey on Drug Use and Health also showed that about 50% of the patients with OUD were not receiving substance use treatment – and that some may be misusing buprenorphine in an effort to self-treat their addiction.

Interestingly, there was no association between buprenorphine misuse and income among those with OUD or with race, ethnicity, or insurance status regardless of OUD status, which bucks commonly held perceptions of those with the disorder.

Overall, the findings “underscore the need to pursue actions that expand access to buprenorphine-based OUD treatment, to develop strategies to monitor and reduce buprenorphine misuse, and to address associated conditions,” the investigators, led by Beth Han, MD, PhD, National Institute on Drug Abuse (NIDA), write.

The study was published online October 15 in JAMA Network Open.
 

Opioid deaths

Centers for Disease Control and Prevention data show more than 93,000 individuals in the United States died from a drug overdose in 2020, a 29.4% increase from the previous year. Of those deaths, 69,710 involved opioids.

Buprenorphine, a medication approved by the U.S. Food and Drug Administration to treat OUD, has been shown to reduce opioid cravings and withdrawal symptoms and lower overdose risk.

The new survey included responses from 214,505 adults. Of these, 51.7% were women, 45.5% were age 50 years or older, and 63.9% were non-Hispanic White.

Responses were collected between 2015-2019 as part of an annual survey administered annually by the Substance Abuse and Mental Health Services Administration.

Misuse was defined as any use outside the prescribed amount, frequency, duration, or indication.

In 2019, hydrocodone, oxycodone, codeine, and tramadol were the most misused prescription opioid products. An estimated 2.4 million adults used buprenorphine, with 1.7 million reporting no misuse in the past 12 months.

While buprenorphine misuse was stable between 2015 and 2019 among individuals without OUD, misuse declined significantly among those with OUD – from 20.5% in 2015 to 15.9% in 2019 (P = .04).
 

A different picture of misuse

The demographic data reveals a picture of buprenorphine misuse that researchers note is quite different from common perceptions about people with substance use.

Those with OUD who misused buprenorphine were more likely to be non-Hispanic White (82.9% vs. 73.6%, respectively) and less likely to live in large metropolitan areas (47.7% vs. 58.1%).

Among participants with OUD, buprenorphine misuse was significantly associated with age, especially in those between 24 and 34 years (adjusted odds ratio [aOR], 2.9; 95% confidence interval, 1.4-5.8) and between 35 and 49 years (aOR, 2.3; 95% CI, 1.2-4.5).

It was also significantly associated with living in nonmetropolitan areas (aOR, 1.8; 95% CI, 1.0-3.0) and having past-year polysubstance use and use disorders (aOR, 3.9; 95% CI, 1.3-11.2); but negatively associated with past-year treatment for illicit drug use–only treatment (aOR, 0.4; 95% CI, 0.3-0.7).

There was no significant association between buprenorphine misuse and income in participants with OUD or with race, ethnicity, or insurance status, regardless of OUD status.

“Perceptions that persons of racial and ethnic minority groups and people living in poverty are more likely to misuse their medication are incorrect,” the researchers write.

“Nevertheless, these factors have been found to be important factors associated with opioid harms and receipt of buprenorphine treatment,” they add.

Between 2015 and 2017, the largest increase in opioid-related drug overdose deaths was among Black people aged 25 to 34, and the largest increase involving synthetic opioids was among Hispanic individuals aged 45 to 54. At the same time, White people were more likely to receive buprenorphine treatment for OUD.
 

‘Don’t exaggerate concerns’

Among survey participants with OUD, 57% of those who had misused buprenorphine in the past year had received no substance use treatment. Among those with OUD who had not misused the drug in the past year, 49% had received no treatment for their addiction.

The most common reason for buprenorphine misuse cited by those with OUD was “because I am hooked” (27.3%), which researchers said suggests people may be taking buprenorphine without a prescription to self-treat their OUD.

The investigators note that although buprenorphine is inexpensive and effective, clinicians currently must receive a federal waiver to prescribe it to more than 30 patients at a time.

Concern over potential misuse may be one reason some clinicians have been reluctant to complete the training process. However, the study results showed misuse rates of other opioids, including oxycodone and hydrocodone, were higher than those reported for buprenorphine.

“Many other prescription opioids are misused at much higher rates,” co-investigator Wilson Compton, MD, MPE, deputy director of NIDA, told this news organization.

“While there are concerns about all of them, we want to make sure that people don’t exaggerate the concerns – and understanding that oxycodone and hydrocodone are so much more frequently misused is important,” added Dr. Compton.
 

Symptom of inadequate access?

Commenting on the research, Bobby Mukkamala, MD, chair of the American Medical Association Board of Trustees, said individuals who misuse buprenorphine “commonly do so to alleviate uncontrolled pain or symptoms of withdrawal.”

“So-called misuse of buprenorphine is a symptom of inadequate access to physicians to treat opioid use disorder,” said Dr. Mukkamala, who also chairs the AMA Substance Use and Pain Care Task Force.

A 2020 study from the U.S. Department of Health & Human Services showed 40% of U.S. counties have no clinicians with a federal waiver permitting them to prescribe buprenorphine in an office setting.

In April, the HHS released new practice guidelines that allow certain practitioners licensed under state law who have a valid Drug Enforcement Administration registration to treat up to 30 patients with buprenorphine without having to complete requirements related to training, counseling, and other ancillary services known as an “X-waiver.”

The move was welcomed by many in the field, but Dr. Mukkamala said the agency did not go far enough.

“The AMA supports removing the federal X-waiver requirement to help destigmatize the provision of buprenorphine as well as remove the many administrative barriers that come with the federal requirement,” he said.

The study was funded by the National Institute on Drug Abuse. The study authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The U.S. Food and Drug Administration (FDA) has approved a combination pill containing celecoxib and tramadol (Seglentis) for the treatment of adults with acute pain severe enough to require an opioid analgesic and for which alternative treatments fail to provide adequate pain relief.

Celecoxib is a nonsteroidal anti-inflammatory drug and tramadol is an opioid agonist. Seglentis contains 56 mg of celecoxib and 44 mg of tramadol.

“The unique co-crystal formulation of Seglentis provides effective pain relief via a multimodal approach,” Craig A. Sponseller, MD, chief medical officer of Kowa Pharmaceuticals America, said in a news release.

Esteve Pharmaceuticals has entered into an agreement with Kowa Pharmaceuticals America to commercialize the pain medicine in the United States, with a launch planned for early 2022.

“Seglentis uses four different and complementary mechanisms of analgesia and offers healthcare providers an important option to treat acute pain in adults that is severe enough to require opioid treatment and for which alternative treatments are inadequate,” Dr. Sponseller said.

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, the FDA will require a Risk Evaluation and Mitigation Strategy (REMS) for Seglentis.

The label states that the drug should be initiated as two tablets every 12 hours as needed and should be prescribed for the shortest duration consistent with individual patient treatment goals.

Patients should be monitored for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with Seglentis.

Prescribers should discuss naloxone (Narcan) with patients and consider prescribing the opioid antagonist naloxone based on the patient’s risk factors for overdose.

Full prescribing information is available online.

A version of this article was first published on Medscape.com.

The U.S. Food and Drug Administration (FDA) has approved a combination pill containing celecoxib and tramadol (Seglentis) for the treatment of adults with acute pain severe enough to require an opioid analgesic and for which alternative treatments fail to provide adequate pain relief.

Celecoxib is a nonsteroidal anti-inflammatory drug and tramadol is an opioid agonist. Seglentis contains 56 mg of celecoxib and 44 mg of tramadol.

“The unique co-crystal formulation of Seglentis provides effective pain relief via a multimodal approach,” Craig A. Sponseller, MD, chief medical officer of Kowa Pharmaceuticals America, said in a news release.

Esteve Pharmaceuticals has entered into an agreement with Kowa Pharmaceuticals America to commercialize the pain medicine in the United States, with a launch planned for early 2022.

“Seglentis uses four different and complementary mechanisms of analgesia and offers healthcare providers an important option to treat acute pain in adults that is severe enough to require opioid treatment and for which alternative treatments are inadequate,” Dr. Sponseller said.

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, the FDA will require a Risk Evaluation and Mitigation Strategy (REMS) for Seglentis.

The label states that the drug should be initiated as two tablets every 12 hours as needed and should be prescribed for the shortest duration consistent with individual patient treatment goals.

Patients should be monitored for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with Seglentis.

Prescribers should discuss naloxone (Narcan) with patients and consider prescribing the opioid antagonist naloxone based on the patient’s risk factors for overdose.

Full prescribing information is available online.

A version of this article was first published on Medscape.com.

The U.S. Food and Drug Administration (FDA) has approved a combination pill containing celecoxib and tramadol (Seglentis) for the treatment of adults with acute pain severe enough to require an opioid analgesic and for which alternative treatments fail to provide adequate pain relief.

Celecoxib is a nonsteroidal anti-inflammatory drug and tramadol is an opioid agonist. Seglentis contains 56 mg of celecoxib and 44 mg of tramadol.

“The unique co-crystal formulation of Seglentis provides effective pain relief via a multimodal approach,” Craig A. Sponseller, MD, chief medical officer of Kowa Pharmaceuticals America, said in a news release.

Esteve Pharmaceuticals has entered into an agreement with Kowa Pharmaceuticals America to commercialize the pain medicine in the United States, with a launch planned for early 2022.

“Seglentis uses four different and complementary mechanisms of analgesia and offers healthcare providers an important option to treat acute pain in adults that is severe enough to require opioid treatment and for which alternative treatments are inadequate,” Dr. Sponseller said.

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, the FDA will require a Risk Evaluation and Mitigation Strategy (REMS) for Seglentis.

The label states that the drug should be initiated as two tablets every 12 hours as needed and should be prescribed for the shortest duration consistent with individual patient treatment goals.

Patients should be monitored for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with Seglentis.

Prescribers should discuss naloxone (Narcan) with patients and consider prescribing the opioid antagonist naloxone based on the patient’s risk factors for overdose.

Full prescribing information is available online.

A version of this article was first published on Medscape.com.

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. 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. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

A version of this article first appeared on Medscape.com.

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

A version of this article first appeared on Medscape.com.

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

A version of this article first appeared on Medscape.com.