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In an attempt to remove a potential barrier to opioid use disorder (OUD) treatment, the Department of Health and Human Services (HHS) announced a plan

Organizations like the American Medical Association (AMA) welcomed the revision. Patrice Harris, MD, chair of the AMA’s Opioid Task Force and the organization’s immediate past president, said the following in the AMA’s released statement: “With this change, office-based physicians and physician-led teams working with patients to manage their other medical conditions can also treat them for their opioid use disorder without being subjected to a separate and burdensome regulatory regime.”

The newly unveiled practice guidelines include an exemption from current certification requirements. The exemption applies to physicians already registered with the Drug Enforcement Administration.

The new HHS policy potentially limits physicians to treating no more than 30 patients with buprenorphine for OUD at any single time. The HSS will make exceptions to this limit for hospital-based physicians, such as those working in emergency departments.

Additionally, the policy change only applies to the prescription of drugs or formulations covered under the X-waiver of the Controlled Substance Act, such as buprenorphine. It does not apply to methadone. The effectual date of the new guidelines will be added after publication in the Federal Register.

The X-waiver has received criticism for years, with one group of doctors writing a 2018 Viewpoint article in 

, titled “Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver.”

 Deregulating buprenorphine, in the opinion of the authors, might be a way to mainstream an effective treatment for OUD.

“Federal policies surrounding buprenorphine constrain its wider use through separate US Drug Enforcement Agency (DEA)–amended licenses (‘waivers’) after approved training,” wrote Fiscella et al. “Removing buprenorphine prescribing regulations in France yielded increases in its use by persons with OUD. Notably, deaths from opioid overdoses in France declined 79% over the subsequent 3 years.”

By removing this waiver, the HHS has hopefully taken a step toward reducing opioid overdose in the United States.

1. Department of Health and Human Services. Announcement of practice guidelines for the administration of buprenorphine for treating opioid use disorder. January 12, 2021. Accessed January 18, 2021. 

https://www.hhs.gov/sites/default/files/mat-physician-practice-guidelines.pdf

2. Young KD. HHS will drop buprenorphine waiver rule for most physicians. 

https://www.medscape.com/viewarticle/944208

3. Fiscella K, Wakeman SE, Beletsky L. Buprenorphine deregulation and mainstreaming treatment for opioid use disorder: X the x waiver. 

The Department of Health and Human Services moves to reduce administrative procedural barriers to OUD treatment. 

Dropping the X-Waiver for Buprenorphine

The Accelerated Development of Additive Pharmacotherapy Treatment for Methamphetamine Use Disorder study, or ADAPT-2 study, discovered that a combination of injectable naltrexone and oral bupropion was safe and effective for treating adults with moderate to severe methamphetamine use disorder. This combination therapy may be a potential treatment addition for those struggling to overcome addiction to methamphetamine.

“The opioid crisis and resulting overdose deaths in the United States are now well known, but what is less recognized is that there is a growing crisis of overdose deaths involving methamphetamine and other stimulants. However, unlike for opioids, there are currently no approved medications for treating methamphetamine use disorder,” National Institute on Drug Abuse (NIDA) Director Nora D. Volkow, MD, said to the press. “This advance demonstrates that medical treatment for methamphetamine use disorder can help improve patient outcomes.”

The research was conducted from 2017 to 2019 at multiple sites within the NIDA Clinical Trials Network (NIDA CTN). The study enrolled 403 adult participants aged 18 to 65 years with moderate to severe methamphetamine use disorder for stage 1, and 225 participants in stage 2. All of these participants wanted to reduce or cease use of the drug.

The study was broken down into 2 stages, 6 weeks each. Participants in the treatment group were given an injection of extended-release naltrexone every 3 weeks and extended-release tablets of bupropion daily. Participants in the control group were given injectable and oral placebos over the same time periods. Adverse events within the naltrexone–bupropion treatment group included gastrointestinal disorders, tremor, malaise, hyperhidrosis, and anorexia. Serious adverse events occurred in 8 of 223 participants who received naltrexone–bupropion during the trial.

At the end of each stage of the trial, researchers gave 4 urine drug screens. If at least 3 of the 4 urine screens were negative, the participant was considered to have responded to treatment.

Over a 12-week period, responses among participants who received extended-release injectable naltrexone plus oral extended-release bupropion was low; however, it was higher than that of the participants who received placebo.

“Long-term methamphetamine misuse has been shown to cause diffuse changes to the brain, which can contribute to severe health consequences beyond addiction itself,” trial leader Madhukar H. Trivedi, MD, of the University of Texas Southwestern Medical Center, Dallas, said to the press. “The good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”

1. National Institutes of Health. Combination treatment for methamphetamine use disorder shows promise in NIH study. News release. January 13, 2021. 

https://www.nih.gov/news-events/news-releases/combination-treatment-methamphetamine-use-disorder-shows-promise-nih-study

2. Trivedi MH, Walker R, Ling W, dela Cruz A, et al. Bupropion and naltrexone in methamphetamine use disorder. N Engl J Med. 2021;384:140-153.

In an ADAPT-2 study, a combination of injectable naltrexone and oral bupropion showed promise for methamphetamine users.  

Medicine Combination With the Potential to Beat Methamphetamine Use Disorder

Opioids continue to be drug most commonly involved in overdose-related deaths in the United States.

 Consequences of this epidemic have, appropriately, been 

 Often overlooked, however, is the persistent scourge of methamphetamine use. The attention and funding dedicated to opioid abuse belies the gravity of methamphetamine use for our patients and health care systems. We call attention to this in hopes that we may avert a similarly lethal methamphetamine epidemic.

Methamphetamine Abuse in Clinical Settings

Working in an urban safety net hospital, our clinical practice is increasingly devoted to the care of patients with stimulant (methamphetamine) use disorder. In 2018, 28% of our hospital admissions involving substances were related to methamphetamines—more than twice the percentage related to opioids.

The behavioral pharmacology of methamphetamine lends itself to aggression, agitation, and violence. Hence, these patients are often brought to care by law enforcement for disturbances in the community. These patients then require intensive treatment given the risk of injury to themselves, other patients, and health care staff. Beyond the effects of acute intoxication, neurotoxic sequelae can result in disabling delusions and hallucinations that persist even after sustained sobriety and are often resistant to pharmacotherapy. This often leads to a misdiagnosis of schizophrenia or bipolar disorder.

 These problematic symptoms and the lack of FDA-approved treatments for methamphetamine use disorders can lead to feelings of helplessness and clinician burnout.

“Michael Warner” is a 56-year-old male with an unknown past psychiatric history. He has been admitted for suicidal ideation and thoughts of hanging himself. He states he has been increasingly depressed and hopeless over the past 3 years because of ongoing harassment by a cartel. His problems started after he witnessed something he should not have at a highway rest stop while working as a truck driver. This caused him to lose his job leading to the dissolution of his marriage and divorce. Mr Warner states that he lives in constant fear for his life and is unable to work, because every several months he has to move to avoid being found by the cartel. He is unable to concretely describe what he witnessed. Mr Warner states he would rather end his life than continue in constant fear.

Collateral information is obtained from Mr Warner’s adult daughter, with whom he is still close. She stated he long-standing struggles with alcohol and began to use methamphetamines in his early 40s. About 4 to 5 years ago, she and her mother had begun to notice increasing paranoia about a drug cartel. Mr Warner insisted the family was being monitored and followed. He lost his job as a truck driver because of behavioral problems at work.

At the urging of his family, he entered treatment for methamphetamine use and has been sober for roughly 2 years. However, his paranoia continued despite several trials of antipsychotics, and his wife divorced him after he became convinced she was an informant for the cartel. Mr Warner minimizes his past drug use, and his mental status exam is normal, with the exception of paranoid delusions. Urine toxicology is negative.

While methamphetamine-induced symptoms are certainly problematic, methamphetamine is also lethal in overdose. In order to lower the cost of production, methamphetamines are often built with other substances of varying toxicity, of which users are unaware. In 2018, 318 Coloradans died from methamphetamine overdoses—the second year that methamphetamine overdose deaths exceeded those from heroin (

 Up to 40% of patients entering medication-assisted therapy for opioid use at our institution are also using methamphetamine, portending poor opioid treatment retention.

This concurrent epidemic has escaped widespread national attention in part because it has remained isolated to less densely populated regions of the country. Whereas fentanyl is most frequently involved in overdose related deaths east of the Mississippi River, methamphetamine is the most frequently involved drug in the 

 Yet, methamphetamine-related presentations are becoming more common nationally as well: between 2008 and 2015, amphetamine-related hospitalizations per 100,000 US adults (mainly comprised of methamphetamine) increased by 245%, increase compared to 46% for opioids and 12% for alcohol.

We must apply the lessons learned from fighting the opioid epidemic to the treatment of methamphetamine-related disorders. Harm reduction measures, including providing clean needles for injection, expansion of contingency management, more aggressive use of pharmacotherapies with even modest evidence, and targeted therapeutic interventions for those in precontemplative stage of change should be extended to populations with high rates of methamphetamine use.

 Education should be provided to health providers on the identification and management of patients with stimulant use disorders. We advocate strong integration of therapeutic approaches with the criminal justice system, given how often we see this patient population come to clinical attention through law enforcement. Certainly, these initiatives will need to account for the impact of the COVID-19 pandemic and resultant interruptions in care accessibility.

The opioid epidemic has cost hundreds of thousands of lives, though arguably it has brought greater access to high-quality substance treatment. There is no reason that a similar number must die from methamphetamine for us to learn the same lessons.

is a psychiatrist at Denver Health Medical Center, Department of Behavioral Health, Denver, Colorado. She is also an assistant professor in the Department of Psychiatry in the University of Colorado, School of Medicine. 

is medical director of Psychiatric Emergency Services

at Denver Health Medical Center, Denver, Colorado

He is also an associate professor of psychiatry in the University of Colorado, School of Medicine. 

is associate research scientist at Denver Public Health and associate professor in the Colorado School of Public Health

is an associate professor of psychiatry at the University of Colorado, School of Medicine and behavioral health medical director for Colorado Community Health Alliance.

1. Hedegaard H, Bastian B, Trinidad J, et al. Drugs most frequently involved in drug overdose deaths: United States, 2011-2016. Centers for Disease Control. National Vital Statistics Reports. 67;(9). December 12, 2018. Accessed December 9, 2020. 

https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf

2. Akiyama K, Saito A, Shimoda K. Chronic methamphetamine psychosis after long-term abstinence in Japanese incarcerated patients. 

3. Grant KM, LeVan TD, Wells SM, et al. Methamphetamine-associated psychosis. 

4. More Coloradans died from meth overdoses in 2018 than ever before. Colorado Health Institute. Published Oct 19, 2019. Updated November 1, 2019. Accessed December 9, 2020. 

https://www.coloradohealthinstitute.org/research/more-coloradans-died-meth-overdoses-2018-ever#:~:text=New%20data%20from%20the%20Colorado,1%2C012%20deaths%20recorded%20in%202017.

5. Tsui JI, Mayfield J, Speaker EC, et al. Association between methamphetamine use and retention among patients with opioid use disorders treated with buprenorphine. 

6. Hedegaard H, Bastian B, Trinidad J, et al. Regional differences in drugs most frequently involved in drug overdose deaths: United States, 2017. Centers for Disease Control. National Vial Statistics Reports. 68;(12). October 25, 2019. Accessed December 9, 2020. 

https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_12-508.pdf

7. Winkelman TNA, Admon LK, Jennings L, et al. Evaluation of Amphetamine-Related Hospitalizations and Associated Clinical Outcomes and Costs in the United States. 

8. Simpatico TA. Vermont responds to its opioid crisis. 

Lessons from the opioid epidemic should be applied to cases of methamphetamine abuse. 

After COVID-19 and Beyond the Opioid Wave

In most cities around the nation, police departments, fire departments, and emergency medical services respond to calls related to substance abuse, emotional distress, and other mental health issues—whether they are trained to handle these issues or not.

But what if there were an equivalent of an EMT or paramedic for psychiatric problems? That is the idea behind CAHOOTS (Crisis Assistance Helping out on the Streets). In this Mental Health Minute, Ben Adam Climer explains the history, philosophy, and efficacy of the CAHOOTS program.

worked for CAHOOTS as a crisis worker for 5 years and an EMT for 2.5 of those years. He now lives in Pasadena, CA where he helps Southern California cities develop CAHOOTS-style programs.

An innovative program sends mental health first responders out onto the streets. 

Paramedics for Mental Health?

The holiday season is usually a time of celebration and joy. But for individuals recovering from substance addictions, this time of year can be emotionally difficult and even lead to a relapse.

In this Mental Health Minute, Jeremy Barnett, LMHC, CASAC, explains why the holidays can be so difficult for individuals in recovery. He also offers practical advice that clinicians can share with their patients.

is a licensed psychotherapist in private practice.

Tips for helping patients preserve their sobriety through the holiday season

Keeping the Holiday Spirit (Without the Holiday Spirits)

Schizophrenia is associated with an increased prevalence of alcohol use disorder (AUD),

 which is also associated with relapse and 

 Adherence with (limited) treatment options for this patient population are suboptimal. Furthermore, patients with comorbid AUD are often excluded from pharmacologic trials in schizophrenia. Therefore, this represents an understudied and difficult-to-treat patient population.

Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), funded by the 

, was a large, long comparative series of trials of antipsychotics for the treatment of schizophrenia.

 As effectiveness trials, CATIE did not exclude patients with substance use comorbidity.

“Ms Norman” is in her 40s and has a longstanding history of 

 and severe AUD. She binges on alcohol episodically, with several months’ sobriety between periods of heavy drinking. Typically, within several weeks of alcohol cessation, she will experience an exacerbation of psychosis requiring inpatient psychiatric hospitalization. She previously lived independently and was able to have part-time employment. Following a recent illness exacerbation, she experienced a period of homelessness for several months, during which she continued to drink alcohol and dropped out of outpatient psychiatric treatment.

 reported on a post hoc analysis of the course of illness in patients with schizophrenia and AUD from the CATIE study. They assessed time to first and recurrent exacerbation, and risks of first and current hospitalization within the 5 years before study entry for patients with this comorbidity, compared with patients with schizophrenia only. They also compared treatment outcomes with olanzapine versus other antipsychotics in these 2 groups. The authors hypothesized that patients with schizophrenia plus AUD would have worse outcomes than patients with schizophrenia alone and, within each group, the advantages of olanzapine for exacerbations and hospitalizations would be retained.

Data for the study were obtained from the publicly available, limited-access CATIE study dataset from the NIMH. Briefly, CATIE was an 18-month, double-blind, randomized trial of perphenazine, olanzapine, quetiapine, risperidone, and ziprasidone in 1493 patients with schizophrenia. The primary end point was time to all-cause discontinuation.

Patients were categorized into schizophrenia and AUD and schizophrenia-only groups (based on DSM-IV criteria). The authors excluded 155 patients with nonalcohol substance-use disorders, except for marijuana use, which was permitted. Exacerbation was defined as hospitalization for psychopathology; more than a 25% or 15-point increase in baseline 

 (PANSS) total score, or significant worsening of key PANSS items; clinically significant aggression or suicidal/homicidal ideation; use of rescue medication; emergency department visit; discontinuation due to lack of efficacy; or arrest or incarceration. Times to first and recurrent exacerbations and hospitalizations were compared, including the reasons leading to exacerbations. In the schizophrenia and AUD group, exacerbations and hospitalizations were compared between patients taking olanzapine and those taking other antipsychotics. There were 303 (23%) participants in the 

 and AUD group and 1035 (77%) in the schizophrenia-only group. Patients with schizophrenia and AUD were significantly younger, had a lower body mass index, were more likely to be male, and had a greater number of hospitalizations in the year prior to study entry than those with schizophrenia only. There was little difference in the prevalence of marijuana use between the 2 groups.

Both the time to first exacerbation (median, 5.4 versus 6.4 months; HR, 1.20) and time to first hospitalization (HR, 1.63) were significantly shorter in the schizophrenia and AUD group than the schizophrenia-only group (

). A similar finding was observed for recurrent hospitalizations (HR, 1.60), although there was only a trend for between-group differences in recurrent exacerbations. More than half (61%) of patients with schizophrenia and AUD had an exacerbation, compared with 52% in the schizophrenia-only group, and the patients with schizophrenia and AUD were more likely to have an exacerbation resulting in hospitalization for psychopathology, due to aggression or suicidal/homicidal ideation, or arrest or incarceration.

Overall, perphenazine, quetiapine, risperidone, and ziprasidone were all associated with a significantly shorter time to first exacerbation compared with olanzapine (HRs, 1.81-2.80). A similar pattern of findings was observed for time to first hospitalization.

The authors concluded that patients with schizophrenia plus AUD had a poorer course of illness, with higher risk of disease progression, compared with patients with only schizophrenia. The investigators also found that olanzapine may be associated with longer time to first and recurrent exacerbations compared with other treatments in patients with schizophrenia and AUD comorbidity.

“Mr Greggs” is in his 30s with a history of chronic schizophrenia and severe AUD, as well as cannabis use disorder. He is currently serving a 1-year probation for a driving-while-impaired citation. He is adherent with monthly administration of a long-acting injectable antipsychotic but continues to drink alcohol and smoke marijuana regularly. He lives at home with his parents and is chronically unemployed. He has not had a psychiatric hospitalization in many years but remains precontemplative regarding the need for treatment for substance use disorder.

Strengths of the present study included the large number of subjects and the real-world design of the CATIE trial. Potential limitations included the post hoc nature of the analysis as well as the lack of generalizability of findings to patients with schizophrenia and other (nonalcohol) substance use disorders. Future trials are needed to identify effective treatment for this patient population.

Patients with schizophrenia with alcohol use disorder comorbidity versus those without have a worse course of illness, and olanzapine may be associated with a longer time to exacerbations versus other nonclozapine antipsychotics.

is professor, Department of Psychiatry and Health Behavior, Augusta University, Augusta, GA. He is the schizophrenia section chief for 

. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain & Behavior Research Foundation, and the Stanley Medical Research Institute.

1. Hartz SM, Pato CN, Medeiros H, et al; Genomic Psychiatry Cohort Consortium. Comorbidity of severe psychotic disorders with measures of substance use. 

2. Bradizza CM, Stasiewicz PR, Dermen KH. 

Behavioral interventions for individuals dually-diagnosed with a severe mental illness and a substance use disorder

3. Jones RM, Lichtenstein P, Grann M, Långström N, Fazel S. Alcohol use disorders in schizophrenia: a national cohort study of 12,653 patients. 

4. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. 

5. Pathak S, Jiang Y, DiPetrillo L, Todtenkopf MS, Liu Y, Correll CU. 

Course of psychosis in schizophrenia with alcohol use disorder: a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness in Schizophrenia phase 1 study

Navigating the treatment options for comorbid schizophrenia and alcohol use

Schizophrenia and AUD

Researchers at Yale University have found that prazosin, a drug developed to treat high blood pressure, can also reduce alcohol use in patients with 

“There has been no treatment readily available for people who experience severe withdrawal symptoms,” 

, an author on the study and director of the Yale Stress Center. “These are the people at the highest risk of relapse and are most likely to end up in hospital emergency rooms.”

Alcohol withdrawal symptoms include shakes, heightened cravings, anxiety, and difficulty sleeping, which can easily lead to poor treatment outcomes.

In order to study the possible effects of prazosin on alcohol use, Sinha and her co-authors designed a 12-week, double-blind trial, recruiting 100 patients with alcohol dependence. The researchers collected information on the participants’ self-reported drinking habits (including average drinks per day) and their moods, levels of anxiety, alcohol cravings, and sleep quality ratings.

At the end of the 12-week study, researchers found that participants with high alcohol withdrawal symptoms who received prazosin reported fewer “drinking” and “heavy drinking” days than patients who received a placebo.

 Patients with high withdrawal symptoms also reported decreased anxiety, depression, and alcohol cravings. Patients with no or low withdrawal symptoms did not receive a similar benefit from prazosin.

Originally developed to treat high blood pressure, prazosin has also been shown to affect stress centers in the brain, improving memory while reducing anxiety and cravings.

 Sinha’s lab has previously found that the recovery process disrupts stress centers in the brain, especially in patients with severe withdrawal symptoms.

Fortunately, these disruptions decrease over time. The hope, Sinha said, is that prazosin could bridge the gap between patients’ initial withdrawal symptoms and long-term recovery.

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. Sinha R, Wemm S, Fogelman N, et al. Moderation of prazosin’s efficacy by alcohol withdrawal symptoms. 

2. Drug eases recover for those with severe alcohol withdrawal. 

. November 19, 2020. Accessed November 25, 2020. 

https://www.sciencedaily.com/releases/2020/11/201119124716.htm

A drug developed to treat high blood pressure has unexpected benefits for patients with severe withdrawal symptoms.

Blood Pressure Drug Benefits Patients Recovering From Alcohol Addiction

 from the Prevention Research Center of the Pacific Institute for Research and Evaluation, child maltreatment is associated with increased risk of substance use among urban female emergency department (ED) patients.

Using a survey of 1037 married/partnered ED patients at a public safety-net hospital, researchers gathered data about at-risk drinking, cannabis, and illicit drug use. At least 1 adverse childhood experience was reported by 53% of men and 60% of women.

Carol Cunradi, the lead author, had this to say to the press: “Health disparities are pervasive among underserved populations, such as those seeking care at urban EDs. So it is important to understand how adverse childhood experiences are linked with substance use among urban ER patients. The prevalence of exposure to childhood maltreatment in this urban ED sample underscores the importance of ED staff providing trauma-informed care to patients, including the delivery of brief interventions and referral to treatment.”

Child maltreatment, or adverse childhood experiences (ACEs), was quantified as exposure to a person with a mental illness in the home; a parent or caregiver with alcohol use disorder; sexual abuse; physical abuse; psychological abuse; and violence directed towards the mother. Participants were assessed on their exposure to the experiences with a brief version of the ACE scale, with 1 question per experience.

Men’s adverse childhood experiences were not associated with increased likelihood of substance use outcomes. Women’s, however, were associated. For example, women with more than 1 adverse experience were more likely to use cannabis or illicit drugs, and women whose mothers were victims of domestic abuse had a greater risk of unhealthy drinking.

Evidence of ACE-related health disparities in urban, low-income populations suggest the need for the development of effective primary prevention, and should be a priority in local, state, and federal entities. In the meantime, EDs may help with secondary prevention and assistance of care in disadvantaged patients.

1. Cunradi CB, Caetano R, Alter HJ, Ponicki WR. Adverse childhood experiences are associated with at-risk drinking, cannabis and illicit drug use in females but not males: an Emergency Department study. 

2. Pacific Institute for Research and Evaluation. Adverse childhood experiences and at-risk drinking, cannabis, and illicit drug use. News release. 

https://medicalxpress.com/news/2020-11-adverse-childhood-at-risk-cannabis-illicit.html 

Female emergency department patients with adverse childhood experiences were more likely to have substance use issues. 

Is Child Maltreatment Associated with Substance Use? New Evidence Emerges

more than half of gay, lesbian, and bisexual individuals who abuse alcohol or tobacco also have a co-occurring psychiatric disorder, whereas only one-third of heterosexual individuals have the same correlation.

“The degree of disparities in alcohol, tobacco and other psychiatric disorders by sexual identity was very surprising,” Rebecca Evans-Polce, assistant research scientist at the University of Michigan School of Nursing and first author of the study, said to the press. “The differences for women are more striking.”

Previous studies have demonstrated that LGBTQ+ individuals are at greater risk for both substance use disorders and psychiatric disorders. Evans-Polce noted that the new study, which gathered data from 35,796 responses from the National Epidemiologic Survey on Alcohol and Related Conditions, is 1 of the few to examine this risk.

An interesting finding of note is the prevalent comorbidities for bisexual women. When compared to heterosexual women, bisexual women were found much more likely to have an anxiety disorder (32.5% bisexual, 16% heterosexual), mood disorder (35% bisexual, 15% heterosexual), and post-traumatic stress disorder (21% bisexual, 6% heterosexual). According to the data, 63% of bisexual women misusing tobacco also had an anxiety disorder, mood disorder, or PTSD. In contrast, only 46% of heterosexual women with a tobacco use disorder also had a psychiatric issue.

Bisexual individuals overall were 4 times more likely to have PTSD than heterosexual individuals.

The reason for this association is unconfirmed, but researchers suspect discrimination and trauma may be to blame. Sexual orientation discrimination, the number of stressful life events, and the number of adverse childhood experiences were strongly associated with greater risk of comorbidities.

Researchers determined that the data demonstrates a need for integrated substance use and mental health prevention and treatment programs, particularly for individuals who identify as sexual minorities. Additionally, more research is needed to comprehend why data repeatedly points to such a high risk for bisexual women.

1. Evans-Polce RJ, Kcomt L, Veliz PT, Boyd CJ, et al. Alcohol, Tobacco, and Comorbid Psychiatric Disorders and Associations With Sexual Identity and Stress-Related Correlates. 

2. University of Michigan. Sexual minorities, especially women, who misuse substances more likely to have psychiatric disorders. News release. 

https://medicalxpress.com/news/2020-11-sexual-minorities-women-misuse-substances.html

Sexual minorities with alcohol and tobacco addictions are at a higher risk for comorbid psychiatric disorders, bisexual women in particular.

LGBTQ+ Individuals who Abuse Substances Are More Likely to Have Psychiatric Disorders

His explanation was clear enough. I was just unable to process what he said. The young man was there for a follow-up outpatient visit, his third since he had been discharged from a 30-day residential substance abuse program. His original ticket to the program had been a short detoxification stay in hospital after an opiate overdose. The overdose had been a close call. The fast action of the paramedic administering naloxone was the only thing that kept him alive.

He was the youngest son of faculty members at a private high school and appeared to have been raised well, in a liberal sort of non-pressured way. Not particularly motivated by his own hopes, he had a bachelor’s degree in fine arts and steady job as a waiter at an east-Asian restaurant. The restaurant’s owner, a motherly figure, gathered the staff together after the restaurant closed for the night and insist that they sit together at the biggest table and consume remarkable portions of the best food as she urged: “Have some more! Have some more!”

This event was perhaps the only socially engaged moment of his week. He lived with a person who he referred to as his girlfriend, but neither of them seemed committed to the relationship. I had noted, but not made much of, the seeming emptiness of his life in prior visits. Even with that caveat, during the prior follow-up visits, I had been able to check all the boxes that represented the agency’s aspirations for his success. He had reported neither cravings nor any sense of missing opiate drugs.

He now described to me his most recent overdose and the experience of coming to consciousness in the ambulance as he was being transported to the hospital emergency department. This time the hospital did not even bother to admit him or notify us that he had overdosed again. Both he and his girlfriend were (to use his term) messing with fentanyl. He was amused at the amazement in my voice when I asked why. “There was nothing good at the movies,” he replied. Yes, they knew that fentanyl was deadly. Still, that risk was part of the fun for them. Not quite as definitive as Russian Roulette, but certainly life-endangering. So, for a second time, his life had been saved by naloxone, which ambulances had only started carrying 10 years ago.

That moment of dumbfounded amazement was my introduction to the opioid crisis, which seems to have only gained momentum since that time. Opioid overdose deaths rose steadily from that date to 2018 when we saw a “

significant decrease … to 46,802 deaths

 Most prognosticators are suggesting that the death rate will rise again as the result of COVID-19, with its emotional stress and enforced lack of productive activity. The medical establishment’s journals and editorials have bemoaned the overly casual prescribing of pain medications as the initiating cause of this great disaster. A regiment of state attorneys general have joined in suits against big pharmaceutical companies for promoting use of high-potency opioids and have impressed juries with their arguments. The accepted story line is that individuals with addiction are being victimized by the availability of opioids in the country.

In my opinion, the media, as well as much of the institutional health effort, has described the opioid epidemic as if it is outside of the larger picture of what some are calling 

. In the year 2018, deaths from heroine (15,000), methamphetamine (13,000), cocaine (15,000), 

 are rising right along deaths due to opioids.

Perhaps it is only a partial truth, but is it possible that individuals who die of these causes do not feel that their own lives are worth protecting? The authorities that society has charged with understanding this rolling disaster are self-motivated and curious individuals who have achieved much in their lives. Is it possible, then, that the existential experience that one’s own life is not worth protecting is so distant from researchers’ experiences that they simply do not or cannot have the imagination to explore this possibility.

 reports: “Emergency department patients who survive an opioid overdose are 100 times more likely to die of an unintentional overdose and 18 times more like to die of suicide within a year than patients who visit the emergency department for other reasons.”

 In addition, “of the 21,080 who were revived from an opiate overdose by ER visit, 368 died within a year of an unintentional overdose,” and another 29 died of what was judged to be an intentional opioid overdose. Other research quotes similar sequences for those revived from sedatives and hypnotics. The conclusion offered is: “patients who survive an opioid overdose, whether unintentional or intentional, should be carefully evaluated for substance use disorders and suicide risk …[and ]… receive appropriate referrals for follow-up substance use and mental health care.”

The previously mentioned study (and many like it) do not explore the possibility that there might be something other than the standard explanation of substance use disorder. Is it not possible to ask whether these individuals are trapped in a world that provides no sense of meaning or engagement for them? Without a sense of meaning or engagement, they might have no reason to protect their own lives and, like the young man who initiated me to this world of despair, would be as happy messing with fentanyl as they would be to go to a good movie in the evening. Spending more money on drug rehabilitation will not move the needle on the death rate for such individuals.

In this conversation I find the pastoral care literature much more relevant than the psychiatric literature. That literature carries the concept of an 

. Orienting systems, or how we think about ourselves, are a specific theme of these Mind-Body Alliance columns. Orienting systems are defined as: “Embedded beliefs and values, perhaps outside of one’s awareness but enacted in one’s practices, especially under stress.”

 The idea of orienting systems is more specifically defined by the psychologist Kenneth Pargament, PhD. I first learned of his work when he presented the Oskar Pfister Award Lecture at the 2009 American Psychiatric Association Annual Meeting.

 His work recognizes that the orienting systems of each individual can be very different. Some are deliberate beliefs that have been taught in formal religious education, but most of them have been informally taught in the school of experience or absorbed by imitation of parents. No matter how a person has assembled their orienting system, Pargament says it must meet 4 criteria

1. Must be complex enough to bear the weight of suffering.

2. Must integrate one’s values and beliefs with one’s actual practice.

3. Must be a flexible enough spiritual basis to cope with stress.

4. Must incorporate beliefs of the goodness of life or goodness of God that foster self-compassion and compassion for others.

The idea that healing from addiction involves spiritual practice is not a new idea. Alcoholics Anonymous (AA)’s

 of makes repeated references to spirituality. In an appendix written shortly after the first edition emerged in 1939, spirituality was explained in this way

Quite often friends of the newcomer are aware of the difference long before he is himself. He finally realizes that he has undergone a profound alteration in his reaction to life; that such a change could hardly have been brought about by himself alone. What often takes pace in a few months could seldom have been accomplished by years of self-discipline. With few exceptions our members find that they have tapped an unsuspected inner resource which they presently identify with their own conception of a Power greater than themselves.

The AA movement continues to be the most effective and most accessible program for alcoholism. Modifications of this format are now widely used for other addictions as well. With the concept of orienting system as our lens, my reading of 

 concludes that the conscious intent of the program was to support individuals in replacing an experience of vacuity with a strong sense of self. I hasten to say not an inflated sense of self, but a self that acknowledges and claims its own scars and wounds. To reflect back to Pargament, a self that is complex enough to bear the weight of suffering, and still claim that life itself is good. Traditional religions, whatever their shortcomings, did convey this sort of orienting system to their adherents. The liberal tradition, wishing to free itself from the baggage of a supernatural lawgiver, appears to me to have not figured out how to sustain the function of incorporating individuals into a functional orienting system.

With some 64,000 individuals dying annually from self-administered recreational drugs in the United States, perhaps the solution lies outside the narrow understanding of medical addiction management, with its focus on dopamine reward systems. Is it possible with our national concern for separation of church and state to work through government funded programs to work on the issue of vacuous lives? Or are we locked into rules that will require us to continue to spend money on things we consider totally secular to deal with a problem that is at base a question of meaning?

This set of columns is titled “Body Mind Alliance: How We Think About Ourselves.” Up to this point I have been referring to how our patients think about themselves. We can, of course, flip the lens and inquire as to how we think about ourselves. What is the orienting system upon which we ourselves rely? Is it not true that we are almost always blind to our own orienting systems and too easily assume that our patients think about themselves in more or less the same way that we think about ourselves? And how is it that we can manage to catch sight of our own orienting system since it is so fully integral to ourselves? Would I have ended up with an understanding of my own orienting system if I had followed the advice of my residency faculty and gone into analysis as my co-residents did? Do we not often lose track of the fact that how we think about ourselves is intensely individual? The parallel to that statement is that how our patients think about themselves is intensely individual and beyond our control or prescription pens. To the degree that we assume the normative nature of our own orienting systems when we talk about deaths of despair, we will altogether miss the main conversation.

is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

The opinions expressed in this article are those of the author and do not necessarily reflect the opinions of 

What do you think? Do you have an orienting system? Is the field’s approach to treating addiction

1. National Institute on Drug Abuse. Overdose Death Rates. March 10, 2020. Accessed November 24, 2020. 

https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. National Institute of on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. Updated October 2020. Accessed November 5, 2020. 

https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics

3. National Institute of Mental Health. Suicide. Accessed November 5, 2020. 

https://www.nimh.nih.gov/health/statistics/suicide.shtml

4. D’Arrigo T. Risk of suicide, unintentional death soar after nonfatal overdose. 

 Journal of Psychiatry. 2009;167(2)226:232. Accessed December 15, 2020. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.167.2.226

7. Pargament K. Spirituality: a pathway to posttraumatic growth or decline? In: eds Calhoun L, Tedeschi R. 

Handbook of Post Traumatic Growth: Research and Practice

Drug use is not only a consequence of addiction. It can also be a response to a deeper, existential problem. 

Addiction & Substance Use