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Tales From the Clinic: The Art of Psychiatry

Tales From The Clinic: The Art of Psychiatry,

 we follow the story of a young man who turned his life around for the sake of his spouse and child, but nevertheless struggled with the tribulations of normal upheaval. Recovery from 

 does not protect against normal life events, but our patients are more sensitive to stress than their nonsubstance user counterparts, increasing the potential for stigmatization. We visit the moral versus brain disease model of addictive processes through the case, and hope to help readers appreciate their own biases and open themselves to understanding the neurobiology of addiction. The aim of proper diagnosis and treatment is to have an objective conception of addiction rather than a morally framed conversation, when behaviors related to addiction are viewed through a negative prism.

“Mr Wallace” is a young man with opioid use disorder and major depressive disorder. He lost contact with his wife and young child as a consequence of his 

. His wife moved to another country, prompting him to get treatment “like I really mean it this time.” He gained sobriety on medication-assisted treatment (buprenorphine/naloxone) and did well, earning advanced certification in his field and increasing his earnings significantly. He also took up the hobby of synthetic music. His wife returned with their child, with subsequent stabilization of the relationship, the purchase of a house, and other life milestones.

The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

 Although NIDA adheres to the brain disease model of addiction (

), there continues to be controversy surrounding whether addiction is a disease or a matter of choice. If addiction is viewed as a moral failing, as posited by the moral model of addiction, then there is the belief that the patient is responsible for their substance use and at fault for having a character defect or a weakness of will.

Advancements in neuroscience have made it possible to identify strong genetic, neurodevelopmental, and sociocultural components of addiction. Evidence pointing to the activation of reinforcement circuits (

) by drugs through the neurotransmitter dopamine in brain areas, such as the nucleus accumbens and ventral tegmental area, further supports irreversible changes in the brain’s structure and function resulting from substance use.

 Because of these permanent changes, it is postulated that individuals cannot exercise self-control over their behavior pertaining to addiction.

This biological approach, supported by animal models of addiction,

 has made room for pharmaceutical treatments of 

. This approach also supports liberation from the belief that addiction is a moral lapse in individuals who have deep character flaws. The disease model of addiction has often been assumed to diminish the attribution of free will to those with drug addictions, which could possibly have significant implications in the attribution of responsibility and stigma as well as the acceptance of treatment.

Critics of the purely brain disease model of addiction believe that categorizing substance use as a disease may further stigmatize individuals with addiction and prevent them from developing self-control, all while damaging their self-esteem.

 and simply diseasing addiction will only further stigmatize those who suffer from addictions. While proponents of the brain disease model of addiction believe adherence to this model will encourage treatment-seeking behaviors, critics believe it will erode the confidence of addicted individuals in their ability to overcome addiction if it is inherently viewed as permanent structural and functional changes in the brain. Research on addictions such as smoking finds that attribution of addiction to unchangeable intrinsic factors leads to lower levels of quitting intentions and quitting self-efficacy.

 Naysayers of the brain disease model of addiction also point out that a clear majority of addicted individuals recover naturally without requiring medical interventions.

Opponents of the brain disease model of addiction believe it: is insufficiently supported by animal-model and neuroimaging data; has only a modest impact on public policies toward drugs and addiction; and has not majorly contributed to the development of more effective treatments despite the decades of research.

 Evidence to support environmental approaches to reducing substance use cautions strongly against the possibility of policy makers and government officials being enticed by the allure of 

. There is some concern that an overly biological emphasis on addiction could take attention away from the necessary social and environmental interventions and divert resources to the production of expensive and perhaps risky medical interventions that can realistically only be accessed by a certain population. 

Proponents of the brain disease model of addiction postulate that adherence will encourage seeking of evidence-based medical assistance to overcome a brain disease. They believe this model lends itself to a collaborative approach between patients and physicians against addiction. However, critics believe the brain disease model of addiction lends itself to addicted individuals absolving themselves of personal responsibility. This results in infantilizing individuals with addictions while shifting the responsibility of overcoming addiction to medical professionals.

 This stark difference in how each model contributes to the physician-patient relationship sheds light on the topic of countertransference (

Mr Wallace later found out—after buying the house, buying a car, and moving back in with his wife and child—that his wife had not been faithful. This led to significant use of Adderall by Mr Wallace and ongoing relationship issues. He continues to have interpersonal issues in the relationship and struggles with maintaining the relationship for the sake of keeping access to his daughter.

, not only does the relationship between the clinician and the patient play a role, but so do the thoughts, beliefs, and experiences of the physician. Besides the brain disease model of addiction, there are several other models that seek to explain the development of substance use. The moral model describes addiction as resulting from a character flaw or moral failing; the choice model sees drug use as a voluntary but harmful behavior; and the psychosocial model regards substance use as related to economic, cultural, and other social factors.

These lead to beliefs about who claims responsibility for beginning and overcoming 

, including the medical model, which regards patients as requiring medical treatment and having low responsibility for the presence and resolution of use; the moral model, which places all responsibility on the patient; the enlightenment model, which states that the individual is responsible for the problem but not the solution; and the compensatory model, which states that the individual is not responsible for the problem but is responsible for the solution.

From studies on treatment providers’ views on the brain disease model of addiction, there seems to be overall support for this concept, although with variations noted among different professions of providers. The strongest support was generally seen in psychiatrists, especially those who were older.

 Interestingly, there was significant evidence of an amalgamation of beliefs, with providers expressing support for multiple models and levels of patient responsibility. These findings extended from treatment providers to treatment settings as well, with examples provided of substance as a “self-induced disease,” bringing together the requirement for medical treatment with responsibility for the initiation and resolution of use belonging to the individual.

 This appears to reflect the complexity of 

 and its treatment, and suggests that the conceptualization of substance use may be tailored to the needs of a particular patient or to the needs of the patient population seeking treatment in a specific setting.

How a physician conceptualizes substance use plays a role in the countertransference experienced. Thinking a patient is willfully making bad choices will obviously decrease positive feelings or wanting to help them, or to go the extra mile in treatment planning. On the other hand, approaching substance use from the brain disease model of addiction helps patients overcome stigma and reduce guilt, as use is not conceptualized as a moral failure of the patient. This may help reduce negative countertransference toward patients with substance use by assisting in understanding frustrating, demanding, or confrontational behavior as not intentional or specifically directed at the provider. Negative countertransference could result in direct consequences, such as avoidance of the patient, difficulty with empathetic responses, and sessions cut short.

This could also increase protective or parental feelings toward patients, especially if they are viewed as helpless against the structural and chemical factors that contribute to their use.

 Such a “positive” countertransference can also lead to difficulty in the therapeutic relationship, as the clinician may take on the role of a parent, becoming overly engaged, protective, and permissive. If the patient then regresses and begins to act out or relapses, the clinician may feel betrayed and subsequently have difficulty in future encounters with the patient. A parental countertransference may also result in the clinician infantilizing the patient and minimizing their strengths and abilities.

 As with all forms of countertransference, the ability to identify and label the ensuing emotion is as critical as the adjustments the clinician must accordingly make.

Although there are many frequently underutilized medications for substance use disorder, a mainstay of treatment relies on naturalistic options such as Alcoholics Anonymous, Narcotics Anonymous, inpatient and outpatient rehabilitation programs, and similar offerings. The Anonymous groups generally involve a 12-step approach that includes concepts of acknowledging addiction as well as the difficulty in overcoming it, recognizing wrongs, making amends for those shortcomings, committing to a life with continued focus on sustained abstinence, and working to help others, especially those experiencing similar struggles with substance use (

Historically, and continuing in the present day, these programs tend to have a strong spiritual component to them, which can be off-putting for some individuals and make it harder to engage. Of the limited data available, there is evidence for the beneficial effect of involvement in 12-step programs for maintaining sobriety, both with and without attending a rehabilitation program. The impact seems to be strongest for those who started attending 12-step groups prior to entering a rehabilitation program and who continued to be involved after completion of rehabilitation. Most of the available evidence is in regard to alcohol use, with less data focused on other substances.

Medicine is far from the conceptualization of addiction as a sin, yet the belief in biological models still lags considerably, as evidenced by suboptimal prescribing of anti-craving medications. In general, evidence-based practices for addiction treatment are still not fully implemented at the scale they could be, and this is likely reflective of how addictive diseases are conceptualized in everyday practice.

is a psychiatry resident at Baylor College of Medicine. 

 is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System in Houston, Texas.

1. National Institute on Drug Abuse; National Institutes of Health. Drugs, brains, and behavior: the science of addiction. 2007. Accessed March 15, 2022. 

https://nida.nih.gov/sites/default/files/soa.pdf

Brain disease or biopsychosocial model in addiction? Remembering the Vietnam Veteran Study.

The science of making drug-addicted animals.

Free will and the brain disease model of addiction: the not so seductive allure of neuroscience and its modest impact on the attribution of free will to people with an addiction.

Addiction and moralization: the role of the underlying model of addiction.

6. Harackiewicz JM, Sansone C, Blair LW, et al. 

Attributional processes in behavior change and maintenance: smoking cessation and continued abstinence.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Drug and alcohol treatment providers’ views about the disease model of addiction and its impact on clinical practice: a systematic review.

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

11. Thomas S, Monico N. The 12 steps of Alcoholics Anonymous. American Addiction Centers. Updated December 20, 2021. Accessed March 15, 2022. 

https://www.alcohol.org/alcoholics-anonymous/

Recovery from addiction does not protect against normal life events...

Normal Life Stress, They Say…

put a spotlight on issues in mental health and wellness, the opioid epidemic shined a light on issues in addiction psychiatry. Even the White House has taken an interest in addressing addiction problems, with President Joe Biden sharing his Administration’s inaugural 

To help address the clinical challenges and issues and provide insight into the solutions and care that might best help your patients, 

 welcomes Roueen Rafeyan, MD, DFAPA, FASAM, as Addictions Section Editor. Dr Rafeyan is chief medical officer of Gateway Foundation in Chicago and clinical assistant professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine. 

 asked Dr Rafeyan a few questions by means of an introduction.

When did you first discover you wanted to be a psychiatrist?

 My interest in behavioral health and psychology started early in my high school years. I enjoyed my entire medical school experience, and I enjoyed every rotation. This made a decision for residency training very hard, as every specialty remained an option.

During my psychiatry rotation, the complexity of the disease states as well as the impact on the person and family along with limited treatment options intrigued me and further sparked my interest.

I followed my heart, even though, at the time, psychiatry training was considered waste of medical education. Although I encountered stigma, I chose to pursue my passion. Thirty years later, I have absolutely no regrets; on the contrary, I am proud and happy about my choice.

Pursue your dreams. The only limitations are the ones that are self-imposed. Bank on your strengths, and enjoy the ride.

What do you enjoy most about being a psychiatrist?

 I enjoy being a physician and a healer. Psychiatry is the only field that requires us to consider the whole person. It is not about an organ that is malfunctioning. In fact, we not only treat the person as a whole, but must also consider their close relationships, social functioning, and family dynamics. The impact of our treatment expands beyond the person, and we can have generational impact.

What most interests you in the field of addictions?

 What interests me the most in field of addiction are the challenges and ever-evolving landscape.

Although the “disease” remains the same, the drugs of abuse are constantly changing with newer synthetic and semisynthetic compounds introduced into market. It requires us as addiction specialists to remain up to date and continue to improve our knowledge in order to provide appropriate care.

What has changed the most since you entered the field?

 So much has changed since I started addiction medicine:

- Recognition has increased significantly. Both the medical community and general public are more aware of its impact.

- Increasingly more residents are showing interest in pursuing further training in addiction medicine.

- Addiction medicine now has its own board certification process and is recognized by the American Board of Medical Specialties.

What are the biggest challenges facing (general) psychiatry today? In addiction psychiatry?

 We are in a much better place now in both psychiatry and addiction medicine, however, there are still many challenges in psychiatry:

- We are facing a serious shortage of psychiatrists, and our approach to inpatient care has changed so much over the years that many times inpatient care has become more of crisis stabilization.

- Coordination of inpatient and outpatient care remains broken, resulting in excessive utilization of services and poorer outcomes.

- Access to psychiatric treatment still remains restricted.

Addiction medicine faces all those challenges and more:

- There is an even greater shortage of addiction specialists, Not many general psychiatrists are interested in supporting these needs.

- Delivery of addiction treatment is fragmented. Historically, treatment has been provided in various settings, by various providers and standards of treatment can be different in each setting.

- The general public are usually not aware of the evidenced base treatment modalities.

- We need more standardized evidence based treatments for addiction across all treatment centers.

If you could impart wisdom on your younger self/earlier in your career in psychiatry, what would it be?

 My career has been very fulfilling, and I have enjoyed the path that has brought me here. I want to share with our early career colleagues an important point:

What do you hope to share with readers as the 

 I would like to share with our readers that addiction psychiatry is a needed and integral part of all fields of medicine, and more so in the field of psychiatry.

I am looking forward to bringing articles and knowledge relevant to readers’ practices and being avaluable resource for common approaches and latest treatment options in addiction medicine.

Do you have questions or suggestions for Dr Rafeyan? Email him via 

A Conversation With an Addictions Psychiatrist

A study found that youth with both attention-deficit/hyperactivity disorder (ADHD) and internet gaming disorder experienced more severe ADHD symptomatology than youth with ADHD who did not have internet gaming disorder.

The purpose of this study was to explore the relationship between ADHD and internet gaming disorder, a new category that was introduced in DSM-5 under “Emerging Measures and Models.” To this end, the investigators recruited 108 participants who had been diagnosed with ADHD (mean age 11.7 ± 2.6 years, 96 males) and 147 normal controls (mean age 13.9 ± 3.0 years, 114 males). All participants completed the Internet Gaming Disorder Scale-Short Form (IGDS9-SF) and the Internet Addiction Test (IAT); the participants with ADHD were assessed for clinical severity using the Clinical Global Impression-Severity Score (CGI-S) and the Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV). Parents of the participants with ADHD also completed the Child Behavior Checklist (CBCL) and the Conners’ Parents Rating Scale—Revised: Short Form (CPRS-R:S). Finally, participants aged 11 to 18 completed the Use, Abuse, Dependence to Internet (UADI) to give the investigators a qualitative assessment of internet addiction.

The results showed that the participants with both ADHD and internet gaming disorder experienced greater impairment and severity of ADHD symptoms, namely higher prevalence of internalizing symptoms, such as problems with socialization and depression/withdrawal, and higher prevalence of evasion and addiction dimensions. The results also supported previous hypotheses suggesting that patients with ADHD have a higher risk of developing internet gaming disorder, as these participants’ IAT and IGDS9-SF scores were at a more than 2-fold higher rate above the cutoff and a more than 4-fold higher score above the cutoff, respectively.

The investigators concluded, “our findings may be helpful for clinicians managing ADHD patients, providing suggestions for diagnostic assessment, the ascertainment of patients at higher risk, and finally, the definition of different phenotypes within the broad category of [internet gaming disorder], with different therapeutic needs, useful for precision medicine.”

1. Berloffa S, Salvati A, D'Acunto G, et al. 

Internet gaming disorder in children and adolescents with attention deficit hyperactivity disorder

Some of the more severe ADHD symptoms noted were depression/withdrawal, problems with socialization.

Study Explores Link Between ADHD and Internet Gaming Disorder

In response to recent reports that 106,854 individuals have lost their lives due to overdose over the past 12 months, the Biden Administration released the National Drug Control Strategy to address addiction and the overdose epidemic. The strategy focuses primarily on untreated addiction and drug trafficking and outlines a plan of action for each effort.

Shortly thereafter, the American Medical Association (AMA) announced that it endorses the strategy’s plan of action for addressing untreated addiction, especially for individuals at highest risk of an overdose.

 Specifically, the strategy calls for the expansion of high-impact harm-reduction interventions such as naloxone; greater access to evidence-based treatment for those at the highest risk of an overdose; and the improvement of research and data systems to guide the development of drug policy.

The strategy also outlines a targeted approach to reducing access to illicit drugs by reducing drug trafficking. It calls for collaboration and coordination on the domestic and international levels to reduce the supply of illicit drugs that are smuggled into the United States, and for the disruption of the financial activities of transnational criminal organizations that manufacture these drugs and traffic them into the United States.

“This sober, clear-eyed report sees the nation’s drug overdose and death epidemic as a public health emergency that requires increased access to a wide variety of harm reduction efforts. Such approaches as increased access to naloxone, drug test strips and syringe services are evidence based, and, if enacted, would save thousands of lives,” said Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force and chair of the AMA Board of Trustees, in a press release. “We also agree with the need to remove all barriers to medications to treat opioid use disorder, including barriers from health insurers as well as those encountered by incarcerated patients and those in recovery homes.”

“The AMA urges all health insurers and state legislatures to take steps to make this strategy a reality. The AMA is a willing partner,” Mukkamala concluded in a press release. “This epidemic has gone on too long and claimed too many lives. We need to make sure evidence-based overdose prevention and treatment is available for everyone.”

Although the strategy supports evidence-based harm reduction interventions and the removal of barriers to medications that can help treat opioid use disorder, some experts suggest that additional attention needs to be paid in the development of new treatments, particularly in regard to fentanyl, and to expansion of the related research beyond opioids.

“To fight the epidemic of lethal fentanyl related overdoses and, more recently, the surge in fentanyl mixed with stimulants like cocaine and methamphetamine, we also need to improve our interventions and develop new [US Food and Drug Administration] (FDA)-approved treatments,” Thomas R. Kosten, MD, told 

™. “Progress is being made in this medication development mission through the [National Institutes of Health] (NIH), and this mission requires expansion of the [Helping to End Addiction Long-Term] (HEAL) research initiative beyond just opioids,” he added. 

Kosten is the Jay H. Waggoner Endowed Chair and co-founder at the Institute for Clinical and Translational Research, as well as a professor of psychiatry, neuroscience, pharmacology, and immunology at Baylor College of Medicine in Houston, Texas.

“The 2022 National Drug Control Strategy needs to recognize this fundamental scientific requirement for adequate control of the expanding lethal epidemic with effective novel interventions like anti-fentanyl vaccines and application of real-time monitoring devices that will deliver overdose reversal agents like naloxone to individuals at high risk of lethal overdoses at the time of those overdoses,” he said.

Fact sheet: White House releases 2022 National Drug Control Strategy that outlines comprehensive path forward to address addiction and the overdose epidemic

. The White House. News release. April 21, 2022. Accessed April 25, 2022.

AMA welcomes public health approach to overdose epidemic

. American Medical Association. News release. April 21, 2022. Accessed April 25, 2022.

Strategy highlights plans of action to address untreated addiction, overdose epidemic.

Support Gathers for Biden Administration’s 2022 National Drug Control Strategy

What is the current state of the opioid epidemic, and what role does naloxone play in the emergency treatment of patients with known or suspected opioid overdose?

These questions and more were addressed in this installment of the custom Around the Practice video program. Panelists for this important discussion included Matthew A. Torrington, MD; Daniel E. Buffington, PharmD, MBA; Thomas R. Kosten, MD; and Bill H. McCarberg, MD.

“This is not a new epidemic,” said Kosten, adding the opioid crisis started as early as 2015. “One can say it was led by the overprescribing of opiates, but what has taken over [the expanding crisis] is fentanyl.”

The panel agreed it has spread across age groups, making it everyone’s problem.

Naloxone may be a solution, Buffington explained, but it may need to be administered several times to counter opioid overdose in emergency situations due to the “increased prevalence of higher-potency fentanyl products” in recent years.

A 27-year-old man presents for evaluation in extreme pain from a car accident. He has a past history significant for substance use disorder, high blood pressure, and diabetes. He takes buprenorphine 2 mg, lisinopril 20 mg, and metformin 500 mg per day. During the next 4 hours, his pain levels vary. Imaging shows a broken ankle, a broken rib, and a small hairline fracture on his clavicle; a CT and MRI show no tissue or brain damage. He gets a cast for his ankle and is started on low-dose opioid therapy—1 oxycodone acetaminophen every 4 to 6 hours as needed for pain for 5 days, until he can see his primary care provider.

This is where the real problems begin, the panel agreed, as the patient is discharged without appropriate pain management. “If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose,” explained Torrington. “I see as a lot of this substandard pain treatment, which makes people—even reasonable people—go to the illicit market to get something else to help them with their discomfort... If we don’t do an adequate job, they’ll take matters into their own hands.”

Acknowledging that this patient is at risk for overdose, the panel discussed the potential use of naloxone.

Kosten recommended 8 mg of naloxone, stating, “If he did go to the illicit market, unfortunately, fentanyl might be in that and you’re going to need a big dose of naloxone to do something.”

McCarberg agreed that this patient is a good candidate for naloxone. “This person has an opioid use disorder—I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it was a subtherapeutic dose,” he explained. “He’s still drinking, he’s smoking cigarettes, all of which put him at high risk for going outside of the standard prescribing realm to get medication...So he really is high risk given all of these factors together. This is the guy that needs the naloxone and a discussion with the wife or whoever’s the other members of the family about what to look out for if he overdoses.”

A 49-year-old unemployed male truck driver is found semiresponsive, and an opioid overdose is suspected. He has a past medical history of high blood pressure, diabetes, obesity, and chronic pain, as well as opioid use following a previous motor vehicle accident. He smokes 1 pack of cigarettes a day, is recently divorced, and lost his job during the pandemic. During the physical exam, he is hypertensive and unresponsive to sternal rub. During the clinical work-up, he has pinpoint pupils, has gone pale, and has clammy skin. His blood pressure is 60/40 mm Hg. His heart rate is 28 beats per minute.

After confirming his airway is clear, he is given supportive breathing and then 8 mg of naloxone intranasally. He is monitored for opioid withdrawal and/or non–naloxone resistance.

“I think you have to think about longer-term treatment,” Kosten said. “Based on the 8 mg of naloxone that it took to reverse him and what is on the street, he probably did get fentanyl in his system. Then the question is: What do you want to treat him with? Could you treat him with naltrexone?” Kosten posed. “An injectable naltrexone lasts a month, so you do not have compliance problems. If he is not opiate dependent, that’s a real possibility.”

“This person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges,” Torrington added. “There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not that much else happens.”

The panel noted it was important to involve the family to prevent negative outcomes.

“I had a recent overdose rescue in my practice, and what struck me was that the wife said, ‘I didn’t know if I should give it or not. I couldn’t tell.’ The question comes up: Should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, error on the side of something that is less harmful to the patient.”

The panel further agreed that to keep patients off the streets looking for medications, care needs to go beyond undertreating pain.

Kosten concluded: “[Providers] have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent—that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.”

is a board-certified family medicine and addiction medicine physician practicing in Culver City, CA. Mr Buffington is president and CEO at Clinical Pharmacology Services in Tampa, FL.

is the Jay H. Waggoner Endowed Chair and professor of psychiatry, pharmacology, immunology, and neuroscience, as well as vice-chair for psychiatry, and codirector of the Dan L. Duncan Institute for Clinical and Translational Research, and a professor of at the Baylor College of Medicine in Houston, TX. He is also on the editorial board for

is founder of the Chronic Pain Management Program for Kaiser Permanente and adjunct assistant clinical professor at the University of California San Diego School of Medicine.

If you missed out on the custom Around the Practice video program on naloxone, we've got you covered. Read a recap here. 

Naloxone as a Tool to Fight the Opioid Epidemic

 What are the things that we can do to try and help educate people, to try and make sure more people know about Naloxone, people know more about opioid use disorder? If you could give people more of what you want them to hear, get on your soapbox and tell me about it.

: I want make a plea to primary care to be more mindful of the fact that we’re undertreating pain and we need to ask about the pain and come up with something that’s more comprehensive psychologically, biologically in every manner of treating the pain. What we’ve done is we opted for the obvious and quick solution by doing opioids. That’s how for a decade we treated people that complained of pain, and we got into trouble with that. What we did then is we withdrew all of that medication and didn’t really address the underlying chronic low back pain from the failed back surgery or the fibromyalgia or the chronic daily headaches or the irritable bowel. We just ignored that, and we need to pay more attention to what other options patients have available. We need to address the pain, and if we do that, it is less likely patients are going to go to the street to get their access to pain medicine; that is no. 1. No. 2, what I see my colleagues doing in California since this requirement is they say, “Well, by the way, here’s a prescription for Naloxone. If you have an overdose that will take care of it. You just need to read the literature.” They’re given that. Without having a longer family visit about how dangerous these drugs are, if they’re going to use them. How dangerous the internet is and how available medication is on the internet, even though it shouldn’t be, and that if they dabble with that, for whatever reason, the chance of them having a death is much higher and that they should become very comfortable with how to use the medication. I was especially impressed with the studies that showed when you had a prescription in a patient’s hand of Naloxone, whichever form they had it, the chance of that patient overdosing is much less. It’s not because they’re using the Naloxone. If they looked at refill rates or how many times they went to the ER [emergency room], they went to the ER less when they have the Naloxone. Not because they used it, but because they were aware of how serious it was. The doctor gave me this medication. The patient says, “Man, this other stuff I’m taking that I have to use this injection for must be pretty serious or he wouldn’t have given me that.” Patients are getting the idea that these pain pills are really dangerous and they shouldn’t take them and we should have that discussion with the patient now when we have the Naloxone, as opposed to just an off the hand, here’s some medication in case you overdose the way we’re doing it now.

: I was just going to say, I would add from a pharmacist perspective is that you have that benefit of having that full profile in front of you and looking for other risk factors. Like we’ve all said, there are times a person may take something and not realize the risk or ramifications. You can highlight that and help them realize that they need to take those medications, respect them for their potential potency or effects, and acknowledge that there are ways to reduce that risk by reducing the opiate burden per se with non-opiates so OTCs [over-the-counters], non-steroidal, other non-pharmacologic, and to communicate clearly with practitioners. The other is to educate on the importance of how properly to administer Naloxone, the role that it plays. Like we’ve said today, when one of those moments happen, that’s a moment that needs additional care and follow-up to evaluate. That risk of reemergence of signs and symptoms don’t look at it as a 1 dose is going to be it for sure. That window afterwards is a critical window to watch for potentially needing to re-administer.

: I have to say it’s hard to add much to all of the comprehensive discussion that we’ve had and the points that Dan and Bill have raised already and, of course, we’ve all raised during this extended discussion. I think the recognition from my perspective as a psychiatrist of comorbid psychiatric disorders among patients who have substance abuse just cannot be emphasized enough. The patients who I typically see come in saying they have, or their family member says they have some substance abuse problem, and they want you to fix it, most frequently it’s because junior does not have the substance problem. What he has is serious depression and he’s, in fact, self-medicating it. This was frequently the case when I’d have high school students or early college students being brought in by their parents saying, “Johnny’s failing at school. He’s at the best places and it’s all going downhill now. I think he’s using some drugs.” The truth was he was using some drugs, and this was a time where the fentanyl was just starting so he wasn’t dying from those drugs, but what he had was serious problems with depression. Treating those depressive disorders is key. If you only take care of this substance abuse and you don’t do anything about the comorbid psychiatric disorder, you’re bound to fail just like psychiatrists have always been accused of trying to make the depression better or make the psychiatric disease better and the substance abuse will take care of itself. Well, that’s certainly not true. You got to take care of both of them and the both of them is the most common kind of presentation that we’re going to see. You have to be prepared to do something about that. Now, whether every primary care doctor is going to be savvy to this, I don’t know. There are lots of people that have the buprenorphine waiver, for example. The average number of patients that many are treating is 3 to 4 patients. It’s clear that we have enough providers for these interventions, but we don’t have them treating enough patients. They’d all have to treat 30 patients or so for us to match what the epidemic proportions are. More providers need to be engaged. They have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent, that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.

: Matt, that brings up a point I want to also make is I had a recent overdose rescue in my practice and what struck me was that the wife said, “I didn’t know if I should give it or not. I couldn’t tell. He sleeps really deeply, and I oftentimes have trouble waking him up normally, not when I’m even worried about him.” The question comes up should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, err on the side of something that is less harmful to the patient.

 Amazing. Another great point. Way to go you guys. I think that just to sum it up, I would say, an overdose is a real thing and it’s prevalent. It’s powered mostly by illicit fentanyl products which have completely taken over the illicit drug market so anybody who’s getting drugs from the internet or from drug dealers, they’re likely to have fentanyl in them. It’s incredibly dangerous and that Naloxone can be lifesaving. In order to have the benefits of lifesaving drugs like Naloxone, you’ve got to have them. They’ve got to be in patient’s hands. Then we got to work on increasing access, increasing education, and trying to save lives, which is our primary job. I think we’re basically out of time, but I just want to thank each of you so much for your time and attention and the expertise that you’ve offered to this session. It’s been incredibly informative. I’ve learned a lot and I really appreciate your hard work and dedication to this. Thank you so much.

This transcript has been edited for clarity.

The panel concludes our discussion with the role healthcare providers play today in the treatment of opioid overdose and what needs to change for the future.

The Role of Healthcare Professionals and Future Directions

 What does that make us think about in that case? What do you think?

: I think several things that I wonder about in this. Is this a guy who just out of the blue, who decided “Let’s go buy some opiates at the local gas station and use them?” There seems to be like we’re missing something in this. High school just isn’t enough of an excuse. I think you have to think about longer term treatment, and I think based on the 8 mg of Naloxone that it took to reverse him and what’s on the street then he probably did get fentanyl in that. Then, the question is what do you want treat him with? Could you treat him with naltrexone? An injectable naltrexone lasts a month, so you don’t have compliance problems. Well, if he’s not opiate-dependent, that’s a real possibility, but I would first check how dependent is he on opiates. Assuming he is, then you’re really talking more likely about buprenorphine, and the buprenorphine dosages, as we said, are minimally now, probably 12 to 16 milligrams a day. Many people get up to 20 milligrams certainly in the VA [Veterans Affairs] population where average dose is 24 mg a day that people are getting. Much higher than we used to use. Now, will that dose block fentanyl? I realize we keep talking about fentanyl and the answer is that dose of buprenorphine will not. It’ll block every other opiate, but it won’t block fentanyl. What could you do? Well, there’s been a recent report sponsored by actually the company that makes the depot buprenorphine, that if you give depot buprenorphine at the 300 milligram dose every month, you get blood levels that are in fact sufficient to block certainly therapeutic dosages of fentanyl, but potentially, maybe twice the dose which would, of course, be potentially a lethal dose in some people. I think that it raises interesting questions about what new treatment alternatives we need to think about. One of them might end up being monthly 300 mg of injectable Sublocade, which is different than the FDA [Food and Drug Administration] guidance, which is they give 300 initially, but then typically shift to 100 per month. If you wanted to keep those blood levels up above 6, which is what you need to do to make it work against fentanyl, you’d need to give 300 every month. There’s no data by the way about whether naltrexone at the standard injectable doses we have, if that would block fentanyl. It will block all the other opiates without a doubt, but whether it will for fentanyl is not at all clear. There are some very interesting questions that get raised about this. What’s hidden behind that curtain of his chronicity with opiate use and what are your options?

: Tom, would he have access to the drug? Namely, would his health care provider if it’s an HMO [health maintenance organization]? If he’s Medicare? Now, he’s 49 years old, so he’s not Medicare and he’s working so he is not Medicaid. Would he have coverage for that, or would it require prior authorization?

: Well, I wish I could say that prior authorization, who would think to do that? Every insurance company apparently thinks to do that and puts you on the line with the social worker to say why you can’t prescribe this medication, which I’ve done. Usually, the injectable medications tend to be on the medical side of the benefit rather than the psychiatric side of the benefit and that’s a huge advantage because they’re used to paying for more expensive things on the medical side I’ve found. When you tell them how much say, just if I can mention a trade name, Sublocade would actually cost for 300 milligrams a month, they don’t bat an eye. If you did that for a psychiatric patient, they would just hang up the phone. Again, I bow to Dan’s expertise on this in terms of anything around cost. It’s not cheap. There’s no 2 ways about it, but I don’t quite know. Dan, do you know much on that?

: Well, there’s a couple of issues packed in there. One is that a lot of pharmacies, like I said, do have access to discounted programs. Certainly, as new products come out there are incentive cards for discounted pricing for patients. That’s something to talk to the manufacturers about but there are state programs from state to state that provide it. Tom, I think you brought up an important point on this case. It doesn’t seem to be complete and one of the issues is this should be a wake-up call. Look at psychosocial factors, the risk factors for depression, the risk factors for substance use disorder. This is an opportunity and I think a commonly expressed shortcoming is to know where do you route these people for that next type of intervention? The other is Matt, I think you brought this up earlier, if used, and we don’t know much about this patient’s background is that’s what we’re talking about now, this would’ve been a moment that is followed up by EMS [emergency medical services] and an intervention for continued monitoring even if it’s to get them routed to some type of support program to get them started. Bill, you brought it up is, and if they don’t have access, and if it does turn out that they are a repetitive user and significant at-risk behavior, then they should be provided the supportive care of access to Naloxone products.

 By the way, great guys, you guys are amazing. I would say that number 1, this person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges. We just got what happened in the ER [emergency room]. They don’t know anything about him. Unfortunately, the ER has never been great at routing these patients into treatment, but fortunately, it’s getting better and better and better. In California, some ERs are even starting buprenorphine, which is amazing. Because you could give this guy Sublocade if you had it in the emergency room right there. You could start them on buprenorphine. You could refer them into treatment. There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not much else happens.

: That’s definitely true, Matt. I see this as a primary care issue because all we have is he has chronic pain, had an opioid use before, but we don’t know what his chronic pain is. How much medication is he taking? What has been done to that chronic pain after this MVA [motor vehicle accident]? Has he been evaluated by physical therapy? Is he on any kind of nonsteroidal? Is it musculoskeletal? Would duloxetine be a valuable adjunct for him to treat his probable depression since he's lost his job in addition to that? I think all of those things need to be addressed and primary care is really a good place to do this because the primary care provider probably knows this patient pretty well, knows the family, has got the inside and outs of what’s happened to this job loss and could really follow up on this in a more comprehensive manner and get to the bottom of it, to send out referrals where needed, and not have this happen again. This guy got very close to dying if you can see, a heart rate of 28, blood pressure real low, and it is not that unusual for him to have something happen like this again if he's not adequately addressed and evaluated right now. It’s the wake-up call like you say, and we need to take the handle on this and run with it because he’s going come in dead next time.

Our experts provide their expertise on Patient Case 2 and how they would proceed with treatment.

Patient Case 2 Discussion

 Well, let’s talk about another case. In this case, it’s a 49-year-old man found semi-responsive to commands with suspected opioid overdose. He has a past medical history for high blood pressure, diabetes, obesity, chronic pain, opioid use following [a] previous motor vehicle accident. He’s a truck driver. He smokes a pack of cigarettes a day. He was recently divorced. He has previous recreational drug use in high school. He has no local family besides his ex-wife. He lost his job due to the COVID-19 pandemic. In his physical exam, he’s hypertensive, he’s unresponsive to sternal rub. On clinical workup, he’s got pinpoint pupils, he’s pale. He has clammy skin. His blood pressure is 60 over 40. His heart rate is 28. For treatment he’s given supportive breathing confirming his airway is clear. He gets 8 mg of Naloxone intranasally. He’s monitored for times of opioid withdrawal and/or non-Naloxone resistance. Repeat Naloxone dose if needed for symptom return, educate patient on risk associated with chronic opioid therapy and prescribe emergency use of antagonist as a safety measure if the opioid use continues.

Dr Torrington moves on to Patient Case 2, a 49-year-old man found semi-responsive with a suspected opioid overdose.

Patient Case 2: 49-Year-Old Man With Suspected Opioid Overdose

 What do you think you’re going to do for this guy? Is he a candidate for naloxone? What do you think so far?

 I’m curious about the fact that he’s being given an opioid on top of the fact that he’s already taking a partial agonist drug buprenorphine. Ostensibly, that medication is for his opioid use disorder. I don’t understand the dose, but that’s why he is taking it. If you were given an appropriate dose for opioid use disorder, this amount of opioid in addition probably wouldn’t treat his pain very well either because it would be antagonized by the buprenorphine.

I’m curious about this whole setup. I don’t know if it’s unrealistic because I don’t know if the ED [emergency department] doctor knows the buprenorphine and the opioid together may not be a good combination. You may need to use more of the opioid if you want to overcome the buprenorphine dose. It’s certainly a risky situation because, at a low dose, the patient may not get enough pain relief and may start taking more of the medication. If the patient was given 100 pills, he would certainly have enough medication to do damage and would need something like naloxone and a discussion with the family on how to use that drug.

But I want to point out that in something like this—the patient now is stabilized, they’re in a cast, they’re going home—there are other options for this patient. Certainly, a nonsteroidal should be thought about. It can be highly effective in a patient like this who has inflammatory pain. We already know the patient got IV [intravenous] Tylenol in the hospital, and his pain level went from 10 to 6. That’s how I read his pain record. Just from the Tylenol he had a lot of pain relief, so maybe Tylenol with a nonsteroidal without adding the opioid would have been a better choice for this guy because he already shows substance abuse disorder, and it’s going to be 5 days before he sees his primary care doctor. I’d probably have him back to the primary care the next day, so you can see how he did with whatever regimen you gave him. That’s how I’d deal with this.

 That’s a key point when we look at the transition from emergency department to home: trying to look at things that don’t create that scenario 5 or even 2 weeks till somebody gets into a particular practice to be evaluated. A more aggressive nonsteroidal would be beneficial, maybe even if there’s a concern over inflammation steroid upon leaving or a 3-day course to get them there as part of what may be driving some of that pain or discomfort. Clearly, a drive for communications on discharge is to specialty practice and shorter windows in that point for care.

As an alternative to this, I’m not sure exactly why he was getting the 2 mg of buprenorphine. But as an analgesic, buprenorphine at 2 mg presumably sublingual is quite a good dose for analgesia. It just doesn’t last that long, so you may have to give it 3 to 4 times a day to get actual analgesia from it. The advantage is that if you were then giving it, what would be the equivalent? At 8 mg a day, at least, that’s a dose that blocks many other opiates and things that he might overdose with. Buprenorphine is a good analgesic. It has a ceiling on it. This is the type of pain that I suspect would be more than sufficient. I bow to Bill’s expertise on whether he thinks that’s true, but these patients I’ve had that have taken 2 mg 4 times a day have gotten some remarkable pain relief from that as well because they’ve had opiates as a problem in the past. We’re dealing with that problem.

 I love all of that. I’ll add a few things. A) You can increase the dose in frequency of buprenorphine. B) You could be more aggressive with your N sets. C) If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose. Part of the point is that I see a lot of substandard pain treatment, which makes even reasonable people go to the illicit market to get something else to help them with their discomfort. Humans don’t want to suffer, and they’ll take a path to help them alleviate their suffering. If we don’t do an adequate job, they’ll take matters into their own hands. I love all those points. That’s really helpful. In California, you’d be giving this person…a prescription for naloxone because anytime you prescribe a controlled substance, you need to do that. In other states, it could be totally worth it. Any other comments about this case before we move on?

 That dose of naloxone I prescribed would be the 8-mg dose because if he did go to the illicit market, unfortunately fentanyl might be in that. Then, you’re going to need a big dose of naloxone to do something about that.

 I want to point out that most of these naloxone compounds are covered by wherever they’re getting their medical care. But if they don’t have medical insurance, it can be very expensive. I called CVS, which has a furnishing ability in California. They don’t need a prescription, so the pharmacy can write a prescription under a state order that they can furnish the dose. I asked CVS, “How much does it cost the patient?” It’s $80 for the nasal Narcan generic, which is a hefty amount if patients don’t have a whole lot of money. If they don’t have insurance, it’s problematic. There are insurance cards that you can get in some places. But without insurance, it can run into a lot of money. You have to be aware of that.

 Bill, you raise a great point in terms of ease of access and affordability. We all get very busy in point-of-care activities, but if you track legislative initiatives in your own states, you’ll find that there’s a lot of those specialty access protocols. In many cases, there’s state-funded access to product for those who fall outside some other type of insurance. Thus, it’s important for each of us to look at what’s happening in our own states that impact our area and communities.

Such great points. As you’re saying that, I’m thinking to myself, “We should dispense the naloxone in the ED.” This guy just was in a car crash. We’re expecting them to go to the pharmacy and get this stuff, and then who knows. If it costs extra, they’re not going to get it. If people had to pay for an AED [automated external defibrillator], would they? No, but it needs to be there anyway. That’s something I thought of that makes sense.

 Matt, another thing is that this person has an opioid use disorder. I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it’s a subtherapeutic dose, but let’s just put that out there. He’s still drinking and smoking cigarettes, which put him at high risk for going outside the standard prescribing realm to get medication, like the internet. So he really is high risk given all these factors. This is the guy who needs naloxone and a discussion with the wife or the other members of his family about what to look out for if he overdoses.

The group discusses Patient Case 1 and how they would treat in this scenario.

Patient Case 1 Discussion

 Our first case is a 27-year-old man who presented with extreme pain in his right ankle, ribs, and arm after getting into a car crash. He has a past medical history, significant for substance use disorder, high blood pressure, and diabetes. He works from home, drinks 1 to 2 cups of hard alcohol when he’s stressed, smokes a pack of cigarettes a day, and is married with 4 children. He takes buprenorphine 2 mg per day, lisinopril 20 mg, and metformin 500 mg. He came into the emergency department [ED]. In the first hour upon arrival at the ED, he described pain as 10 of 10. He got 1 g Tylenol IV [intravenous]. In the second hour, he had 6 of 10 pain. There was no comment about his pain and what they gave him then. In the third hour, 7 of 10. In the fourth hour, 10 of 10. The imaging showed a hairline, a broken ankle, a broken rib, and a small hairline fracture on his clavicle. CT and MRI showed no tissue or brain damage. He got a cast for his right ankle and then got started on low-dose opioid therapy, Percocet 5/325 [5 mg oxycodone hydrochloride, 325 mg acetaminophen], 1 every 4 to 6 hours as needed for pain for 5 days until he gets to his primary care provider.

Matthew A. Torrington, MD, introduces our first patient case, a 27-year-old man presenting with injuries from a car accident.

Addiction & Substance Use