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According to a recent report from the Centers for Disease Control and Prevention (CDC), overdose deaths in 2020 are up 30% compared to 2019, the largest increase in at least 50 years. In response to the deaths of more than 93,000 Americans from drug overdoses, the American Psychiatric Association (APA) renewed its call to action.

“This week’s CDC report is a devastating reminder that the opioid crisis continues and, as we suspected, reached tragically high levels during the pandemic,” said Vivian Pender, MD, APA President. “It’s critical that policymakers continue to take action to save lives, and that families and patients know that treatment works.”

The APA stated the following 3 items are important to focus on:

1) Improved access to mental health and substance use care via early identification in evidence-based models that integrate behavioral health treatment into primary care services.

2) The development and implementation of science-based policies and programs to provide effective substance use disorder treatment for all patients, created through a review and discussion with Congress, federal policymakers, and experts in the field of addiction treatment.

3) Policies and programs to support accredited medical schools and residency programs in training clinicians to manage substance use disorders.

“The federal government and the states have taken a number of actions to address the opioid crisis, and APA has been supportive of those actions,” said APA CEO and Medical Director Saul Levin, MD, MPA. “A critical step in addressing the problem is ensuring early identification of substance use disorders and that all physicians have the adequate training to recognize and treat opioid use and substance use disorders when they see it.”

(Are you seeing increased cases of opioid use disorder (OUD)? Do you have any pressing concerns or questions about OUD or success stories to share? Write to us at

. Your story may be included in an upcoming special discussion on OUD—Ed)

1. American Psychiatric Association. American Psychiatric Association renews call to action after dramatic increase in overdose deaths. July 16, 2021. Accessed July 19, 2021. 

https://www.psychiatry.org/newsroom/news-releases/american-psychiatric-association-renews-call-to-action-after-dramatic-increase-in-overdose-deaths

After the largest increase in overdose deaths in 50 years, the American Psychiatric Association sends out the call for improved substance use care. 

Fighting the Opioid Epidemic: The APA’s Call to Action

The first participant has officially enrolled in Orexo’s study of digital therapeutic modia, part of a clinician-supervised treatment program for the treatment of opioid use disorder (OUD).

“When it comes to treating OUD, research has proven time and time again that we need to take a whole-person approach by addressing both the physical withdrawal symptoms and the mental health issues associated with addiction,” said Nikolaj Sørensen, President and CEO of Orexo. “Yet, all too often, the resources needed to effectively do so just aren’t available. The enrollment of our first patient in the pivotal study of modia™ is a significant milestone toward closing that treatment gap and allowing more people easy access to a tool designed to support them in the battle against addiction.”

In this randomized, open-label, parallel-group study, modia will be evaluated in combination with sublingual buprenorphine/naloxone background therapy to see whether it is superior to sublingual buprenorphine/naloxone alone in reducing opioid use. An estimated 400 participants at 35 sites will be enrolled across the US and evaluated over 24 weeks, including a screening period where they will be stabilized on buprenorphine/naloxone. These participants will be volunteers aged 18 to 65 seeking treatment for moderate to severe OUD.

This news comes just in time to meet a rising need: The opioid epidemic has grown by 36% during the COVID-19 pandemic, with the number of fatal opioid overdoses reaching more than 67,500, from December 1, 2019, to November 30, 2020.

Additionally, modia aims at helping users develop a customized relapse prevention plan, structured using the responses collected throughout the program.

“A great deal of work went into designing and building modia to deliver a unique digital therapeutic for patients struggling with OUD,” Mike Sumner, Chief Medical Officer of Orexo, said to the press. “We fully anticipate that the outcomes of the study will prove that modia can be a valuable addition to existing treatment plans for patients with OUD when paired with medications like buprenorphine/naloxone.”

1. Orexo. Orexo announces first patient enrolled in pivotal study evaluating the efficacy of modia™ in combination with sublingual buprenorphine/ naloxone for the treatment of OUD. News release. July 1, 2021. Accessed July 15, 2021. 

https://orexo.com/posts/2021-07-01-orexo-announces-first-patient-enrolled-in-pivotal-study-evaluating-the-efficacy-of-modia-in-combination-with-sublingual-buprenorphine-naloxone-for-the-treatment-of-oud

2. Centers for Disease Control and Prevention. Provisional drug overdose death counts. June 16, 2021. Accessed July 15, 2021. 

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#dashboard

Novel digital therapy modia will be evaluated in combination with sublingual buprenorphine/naloxone background therapy to see whether it is superior in reducing opioid use.

First Participant Joins Opioid Use Disorder Treatment Study 

Addiction, while a mental health disorder in its own right, often covers deeper wounds. Treating addiction often requires a willingness to delve deep into a patient’s psyche and find the traumatic experiences that are motiving the substance abuse.

In this Mental Health Minute, Gray talks about her efforts to treat the traumas that often lurk behind addictions. She offers tips for building strong therapeutic alliances and recommends using eye movement desensitization and reprocessing to help patients with comorbid substance abuse disorders and trauma.

is a licensed therapist and recovery coach at Hand in Hand Counseling in Greenwich, CT.

The potential role of eye movement desensitization and reprocessing.

Treating Comorbid Substance Abuse and Trauma

The rise in synthetic cathinone and cannabinoid use has been linked to a wide range of 

, including agitation, psychosis, and delirium.

 Managing and stabilizing the complex toxic effects of these drugs can be challenging.

Colloquially known as spice, these designer synthetic cannabinoid receptor agonists have potent 

 at the cannabinoid (CB) 1 and 2 receptors.

 The compounds were originally developed to study the endocannabinoid system, but they emerged as a drug of abuse in 2008.

 Initially designed to mimic the effects of 9-tetrahydrocannabidiol, synthetic cannabinoids are 2 to 100 times more potent than marijuana at the CB1 and CB2 receptor, resulting in a range of adverse neuropsychiatric symptoms (

 Furthermore, synthetic cannabinoids are often adulterated with ingredients to either enhance or attenuate the drug high, resulting in clinically unpredictable toxicological profiles.

 As a consequence, no specific toxidrome is associated with synthetic cannabinoid intoxication, and patients will typically present with a constellation of sympathomimetic, anticholinergic, and marijuana toxic effects (

 The most common sympathetic nervous system cardiovascular effects are tachycardia (46%) and hypertension (21%). The anticholinergic effects closely overlap with signs and symptoms of a sympathomimetic toxidrome. Distinguishing symptoms specific to anticholinergic toxicity include dry skin, “cotton mouth,” absent bowel sounds, blurred vision, and urinary retention. Patients may also present with marijuana intoxication symptoms (eg, ataxia, delayed reaction time, and conjunctival injection). Laboratory studies are indicated in cases of severe intoxication with agitation or seizures; the potential metabolic derangements that can result may be life-threatening.

Colloquially known as bath salts, these agents are synthetic psychostimulants structurally related to cathinone, a monoamine alkaloid found in the khat plant. They are commonly abused for their euphoric, empathogenic, and stimulating effects. As substituted phenethylamines, synthetic cathinones are structurally and pharmacologically similar to amphetamine and 3,4-methylenedioxymethamphetamine (MDMA). The 

 synthetic cathinones are 4-methylmethcathinone (mephedrone), 3,4-methylenedioxy-N-methylcathinone (methylone), and 4-methylenedioxypyrovalerone.

Synthetic cathinones produce major effects on the central nervous system and are linked to adverse neuropsychiatric complications (

 stimulate the release of dopamine and inhibit the reuptake of epinephrine, norepinephrine, and serotonin, inducing a broad range of sympathomimetic, serotonergic, and hallucinogenic adverse toxidrome effects (

 The most frequent sympathetic nervous system cardiovascular effects are tachycardia (46%) and hypertension (21%). The hallucinogenic effects (ie, perceptual distortions, depersonalization, synesthesia) can be highly distressing, often prompting emergency psychiatric care. Ancillary lab studies should be ordered in cases of severe agitation because of the increased risk for acute kidney injury, rhabdomyolysis, lactic acidosis, stroke, and intracranial hemorrhage.

The diagnosis of intoxication is based on a history of exposure and presence of characteristic signs and symptoms. Patients may unknowingly or inadvertently administer synthetic cannabinoids and cathinones, as these compounds are often adulterated with 

 Patients will typically present with signs and symptoms of adrenergic neurohumoral activation.

 The neurotoxic symptoms (eg, aggression, confusion, and psychosis) may overlap with a primary mental illness; psychiatrists should rely on the clinical history and physical exam findings for an accurate diagnosis. In the setting of acute intoxication, urine immunoassay testing has a low positive predictive value for synthetic cannabinoids and cathinones.

 The molecular geometry of synthetic cannabinoids and cathinones is ever changing, making it increasingly difficult to identify these compounds via gas chromatography/mass spectrometry, which may not be readily available to assist in the diagnosis process.

 An atypical onset of psychosis and agitation alongside hypersympathetic activation and a mixed toxidrome is strongly suggestive of intoxication.

Psychiatrists should strongly consider the possibility of intoxication in any patient with no known psychiatric history, a negative urine drug screen, and no known contributing medical mimickers presenting with a mixed toxidrome. Patients will not necessarily fit neatly into a particular toxidrome; rather, they present with overlapping signs and symptoms from multiple toxidrome classes. Consequently, differentiating synthetic cannabinoid and synthetic cathinone toxicity can be challenging. Regardless, supportive care and symptom management is the mainstay of the treatment. Benzodiazepines are considered the first line of treatment to reduce the 

 (eg, hypertension, agitation, and seizures).

Agitation is the most common neuropsychiatric complication associated with synthetic cannabinoid and cathinone ingestion. In fact, according to one report, 40% of intoxicated patients evaluated in an ED will experience severe agitation.

 The spectrum of psychomotor agitation can be objectively measured and identified with a standardized rating scale such as the Behavioral Activity Rating Scale (BARS). For patients with mild-to-moderate agitation (BARS score = 5 or 6), the patient may initially be calmed with verbal de-escalation techniques and environmental modification. For patients with moderate-to-severe agitation (BARS score > 6), benzodiazepines remain the first-line treatment.

Among the benzodiazepines, midazolam and lorazepam are considered the initial drugs of choice for decreasing agitation because of their rapid onset of action, short half-life, and parenteral route of administration availability.

 Antipsychotics are commonly administered with benzodiazepines to manage the psychotomimetic effects.

 However, risks associated with antipsychotics in acute poisoning settings must be carefully considered since they may increase the risk of seizure induction, have anticholinergic effects, impair thermoregulation mechanisms, and prolong the QTc interval.

 Serotonergic sedatives such as fentanyl should be avoided because of the increased risk of serotonin toxicity associated with synthetic cannabinoids and cathinones.

A systematic review reported that 25% to 94% of patients diagnosed with excited delirium were recently exposed to synthetic cannabinoids and/or cathinones. The American College of Emergency Physicians has provided guidance on evaluating excited delirium, for which a minimum of 6 of 10 clinical criteria are required to make a diagnosis. If undertreated, the case-fatality rate is estimated to be 20%, partly due to catecholaminergic cardiorespiratory failure. The cornerstone of treatment is rapid sedation to reduce the sympathomimetic outflow and facilitate lifesaving treatments.

To date, no large-scale randomized controlled trials have evaluated pharmacological treatments for excited delirium. Nonetheless, the standard of care is to administer benzodiazepines and antipsychotics to decrease psychomotor agitation. In the emergency setting, intramuscular (IM) ketamine (4-5 mg/kg) is increasingly used for sedation of agitated patients with excited delirium. Initial studies in the prehospital setting (emergency medical services) reported that intubation rates following ketamine administration were as high as 60%. Emerging literature supports that IM ketamine administration in the hospital setting (ie, ED) is a safe and effective treatment for excited delirium while not significantly affecting the cardiopulmonary system.

 reported that more patients required intubation after ketamine administration in the prehospital setting (30%) compared with the hospital setting (1.8%). Prospective studies conducted in the ED have demonstrated that there is no significant difference in incidence of complications between IM ketamine and IM haloperidol.

 The adverse effects of single doses of IM ketamine for agitation are generally transient and self-limiting; they include emesis, hypersalivation, recovery agitation (also known as emergence reaction), hypertension, and tachycardia. Moreover, ketamine has other potential benefits, including a faster onset to sedation compared with benzodiazepines and antipsychotics.

 There are observational reports of ketamine exacerbating psychosis in susceptible patients. Larger studies, however, have concluded that acute- and short-term ketamine administration for agitation does not increase psychiatric inpatient admissions or ED psychiatric evaluations.

 Physical restraints should be used as a last resort, primarily as a bridge to pharmacologic treatment, as prolonged use of physical restraints is likely to worsen delirium and rhabdomyolysis, as well as lead to renal failure, electrolyte abnormalities, and arrhythmias.

Synthetic cannabinoids have been linked to psychotic reactions, such as paranoia, catatonia, and dissociation, as well as auditory and/or visual hallucinations.

 Longitudinal studies have reported that consumption of potent cannabinoids quintuples the risk of a psychotic episode.

 The psychotomimetic effects are usually transient and resolve within 5 to 8 days; however, up to one-third of patients will transition to schizophrenia.

 Although there is no established antidote, preliminary reports suggest that cannabinol, an allosteric modulator at the CB1 receptor, may reverse the neurotoxic effects.

Similarly, synthetic cathinones have propsychotic effects, potentially triggering a psychotic state in vulnerable patients. An observational study reported that synthetic stimulants were implicated in approximately 25% of ED visits involving drug-related psychosis. Specifically, mephedrone was the most common synthetic cathinone involved, accounting for approximately 20% of stimulant-related psychotic cases.

 Synthetic cathinone-induced psychosis is typically brief and resolves within days to weeks; however, 25% of patients will transition to a schizophrenia spectrum disorder.

The psychotomimetic symptoms can be controlled with first- and second-generation antipsychotic medications with careful consideration of adverse effect profiles. Among the first-generation antipsychotics, the butyrophenone neuroleptics IM haloperidol and IM droperidol are reasonable pharmacotherapeutic options.

 In comparison with IM haloperidol, IM droperidol has a faster onset of action; it rapidly prevents and treats emergent psychotic agitation within 5 to 10 minutes of IM administration.

 Some expert panels have recommended avoiding butyrophenone neuroleptics in cases of substance-induced psychosis due to its proconvulsant properties, cardiotoxic effects, and extrapyramidal symptoms.

Among the second-generation antipsychotics, po olanzapine has a track record of treating NPS-induced psychosis, and prodrug websites have touted olanzapine as the ideal medication to terminate “bad trips.”

 In spite of its efficacy, olanzapine has anticholinergic and central thermoregulatory effects that impair core temperature regulation. In theory, po or IM aripiprazole and ziprasidone are probably the safest antipsychotics to administer because of their relatively favorable safety profile and negligible anticholinergic and seizurogenic effects.

Despite the infamous concerns about QTc prolongation, epidemiological studies do not support a correlation between ziprasidone and torsades de pointes. In many instances, detoxification with benzodiazepines and rest will often quell the substance-induced symptoms without the added need for antipsychotics. Given the risks associated with neuroleptics, especially in patients who are antipsychotic naïve, it may be best to consider a benzodiazepine as the first-line agent to reduce the psychotic agitation. Antipsychotics can be initiated if the psychosis continues to persist after the detoxification period, or if the patient has an underlying primary psychotic illness.

Synthetic cannabinoid and cathinone harms are increasing. Synthetic cannabinoids and cathinones have propsychotic and agitative effects, and the toxic reactions can mimic a primary mental illness. Because no definitive diagnostic test differentiates primary vs secondary drug-induced mental illness, psychiatrists must rely on the history and physical examination.

 is an assistant professor of medical education and psychiatry at California University of Sciences and Medicine, Arrowhead Regional Medical Center, in San Bernardino.

 is a core faculty member for the Internal Medicine Residency Program at Arrowhead Regional Medical Center, San Bernardino. The authors have no relevant financial disclosures to report.

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7. Weinstein AM, Rosca P, Fattore L, London ED. Synthetic cathinone and cannabinoid designer drugs pose a major risk for public health. Front Psychiatry. 2017;8:156.

8. Baumann MH, Walters HM, Niello M, Sitte HH. Neuropharmacology of synthetic cathinones. Handb Exp Pharmacol. 2018;252:113-142.

9. Oliver CF, Palamar JJ, Salomone A, et al. Synthetic cathinone adulteration of illegal drugs. Psychopharmacology (Berl). 2019;236(3):869-879.

10. Riederer AM, Campleman SL, Carlson RG, et al; Toxicology Investigators Consortium (ToxIC). Acute poisonings from synthetic cannabinoids – 50 U.S. Toxicology Investigators Consortium registry sites, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(27):692-695.

11. Arntson A, Ofsa B, Lancaster D, et al. Validation of a novel immunoassay for the detection of synthetic cannabinoids and metabolites in urine specimens. J Anal Toxicol. 2013;37(5):284-290.

12. Moeller KE, Kissack JC, Atayee RS, Lee KC. Clinical interpretation of urine drug tests: what clinicians need to know about urine drug screens. Mayo Clin Proc. 2017;92(5):774-796.

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31. Valeriani G, Corazza O, Saverio Bersani F, et al. Olanzapine as the ideal “trip terminator”? analysis of online reports relating to antipsychotics’ use and misuse following occurrence of novel psychoactive substance-related psychotic symptoms. Hum Psychopharmacol. 2015;30(4):249-254. ❒

Cannabis has been heralded as a treatment for many conditions, but what about its psychiatric risks? 

The Rise in Synthetic Cannabinoids and Cathinones

Rhode Island Governor Daniel McKee recently signed a bill that authorizes a 2-year pilot program 

 In these centers, people can consume pre-obtained substances under the supervision of trained staff.

There are approximately 120 similar programs operating worldwide, but Rhode Island is the first US state to pass a law authorizing the implementation of harm reduction centers for supervised drug consumption.

In response to the news, Managing Director of Policy for the Drug Policy Alliance, Lindsey LaSalle, said: “Today’s victory in Rhode Island gives us hope that there are policymakers that are willing to actually lead and do what needs to be done to save lives in the face of one of the worst public health crises of our time. With at least 92,000 of our friends and family members lost to overdose in 2020 alone, we simply cannot wait any longer. We have to use every public health resource at our disposal—especially the ones we know work. And we have to do it now. There are mountains of evidence, from years and years of experience in other countries, to show that 

, increase the likelihood of a person entering treatment, and provide people access to other vitally important health resources.”

Harm reduction centers provide a hygienic and safe space for people who use drugs. Center staff members do not directly assist in the consumption of any drugs brought in by clients. Instead, staff will: provide sterile equipment and supplies, answer questions on safe consumption practices, administer first aid if needed, monitor for overdose, offer general medical advice, and offer referrals to drug treatment, medical treatment, and other social support programs.

Harm reduction centers also reduce health and public order issues by targeting high-risk, socially marginalized drug users who would otherwise inject in public spaces. These services are not intended to replace existing prevention, harm reduction, and treatment interventions, but instead complement them.

“Our general assembly and Governor's office has been very supportive of helping people with substance use disorders, people who use drugs, and people in recovery and really actively engaging with those populations to move this law along. We hope this will set a precedent for other states to follow suit, with Rhode Island being the leader,” said Haley McKee, co-chair of the 

Substance Use Policy Education & Recovery PAC

1. State of Rhode Island General Assembly. Harm reduction center pilot program to combat overdose deaths becomes law. News release. July 7, 2021. Accessed July 8, 2021. 

http://www.rilin.state.ri.us/pressrelease/_layouts/RIL.PressRelease.ListStructure/Forms/DisplayForm.aspx?List=c8baae31-3c10-431c-8dcd-9dbbe21ce3e9&ID=371925

2. Drug Policy Alliance. Drug Policy Alliance statement on Rhode Island becoming first in the nation to authorize harm reduction centers to prevent overdose deaths. News release. July 7, 2021. Accessed July 8, 2021. 

https://drugpolicy.org/press-release/2021/07/drug-policy-alliance-statement-rhode-island-becoming-first-nation-authorize

To combat drug overdoses, the Rhode Island governor signed a bill allowing people to consume pre-obtained drugs under safe, professional supervision of trained staff. 

Rhode Island: The First State to Allow Harm Reduction Centers for Safe Drug Consumption 

During the past year, the COVID-19 pandemic has exacerbated the already severe substance abuse and mental health crises in the United States. Isolation and economic hardship have triggered spikes in depression, posttraumatic stress disorder, anxiety, and abuse of substances.

This unprecedented confluence of events, along with a welcome decrease in mental health stigma, has fueled a surge in demand for behavioral health services. According to a survey by the National Council for Behavioral Health (NCBH), 

of community behavioral health organizations reported greater demand for services through August 2020, while half of organizations offering substance use disorder (SUD) services saw demand jump last summer.

Unfortunately, many of these organizations are poorly positioned to meet this increased need for treatment services due to financial struggles. Nearly 65% of them have had to cancel programs, reschedule services, or turn away patients due to lack of revenue or pandemic-related restrictions. For some, the situation is dire: Nearly 40% of these organizations reported they may not last 6 months, given their revenue shortfalls.

On top of patient demand and financial struggles, the disjointed and siloed crisis management infrastructure makes it difficult for individuals in crisis to receive the care and resources they need. Lacking access to appropriate behavioral health care, many in crisis turn to emergency departments (EDs). An analysis 

 in February 2021 of nearly 190 million ED visits revealed that “visit rates for mental health conditions, suicide attempts, all drug and opioid overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019.”

Even before the pandemic put an immense strain on the behavioral health care system, the 

Substance Abuse and Mental Health Services Administration

 (SAMHSA) was pushing for the standardization of crisis management across the US for any behavioral health condition.

SAMHSA’s goal is to standardize care quality and care delivery processes based on the best evidence-based practices. In other words, we know what works and how to keep individuals out of the medical care and criminal justice systems. We now need to implement the right processes broadly. A key part of the infrastructure is a new number for the National Suicide Prevention Lifeline (NSPL), which is run by SAMHSA. A bill signed into law late last year designates the 

 as the new, easy-to-remember phone number for anyone in crisis trying to reach the NSPL.

The 911 line currently is used for all emergencies, including mental health and substance use emergencies. But behavioral health crisis calls that result in the involvement of law enforcement sometimes result in tragic and traumatizing outcomes. In contrast, calls to the 988 mental health crisis number will be handled by trained NSPL counselors, who can in turn dispatch trained clinicians to a caller’s location. This behavioral health hotline number is expected to go live in July 2022.

Providing a hard-to-forget number will not make much of a difference, however, if we are not able to standardize the quality of crisis care across the US. Currently, there are about 

 that a caller could be patched through to, depending on area code.

 Those crisis lines offer varying degrees of services. Some are staffed by volunteers and non-clinicians who may lack experience and training, while others are staffed by veteran clinicians. Some can quickly connect callers to definitive assessment, treatment, and mobile crisis services. Others do not have these capabilities. 

To address this challenge, in February 2020, SAMHSA released its 

National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit

 Aimed at behavioral health authorities, agency administrators, service providers, and state and local leaders, this document defines national guidelines for crisis care. It also offers tips for implementing care that are in alignment with national guidelines as well as tools to evaluate whether systems are aligned to those guidelines.

The guidelines published by SAMHSA lay out a vision for a 

 integrated crisis system in which, based on the caller’s needs, the appropriate type of care can be quickly identified and provided. Nobody is turned away. Elements of this system include a regional, clinically staffed crisis call center that provides multichannel intervention capabilities and quality coordination of crisis care in real time, a mobile crisis team that can reach any person in the service area, and short-term (23 hours) crisis facilities for receiving and stabilizing patients in a nonhospital environment.

SAMHSA is encouraging all states to set up this standard clinical infrastructure. The states will need the technology to coordinate clinical activity and provide situational awareness—this is where care behavioral-health-specific coordination tools come in. An example of such a tool includes a cloud-based software platform with real-time availability of inpatient and outpatient treatment services, connections to treatment and social support services, and evidence-based assessment tools. It is important to identify a solution that helps clinicians close the loop on their patients’ care.

These goals and guidelines for behavioral crisis management are welcome news. Yet some would argue that instead of spending time and money 

 is not synonymous with prevention, but the goal of an end-to-end crisis system is to divert individuals from the inpatient beds and prisons, where they rarely get definitive behavioral healthcare. In addition, crisis systems provide preventative care: some of the data regarding crisis center calls shows that only 10% end up with a mobile team being dispatched to someone’s home. Of those calls, 80% are stabilized and do not require transfer to an inpatient care setting. Finally, of those who are transferred to a 23-hour crisis stabilization center, I estimate 75% are discharged home.

A very high percentage of the calls are being deescalated right on the line. But what then? With the right clinical and technology infrastructures in place, behavioral health crisis centers can refer callers to appropriate definitive assessment and treatment. In doing so, they can play a role in preventing callers from suffering a worsening of their current clinical condition, recurrence of this, or involvement with the medical care system and law enforcement.

To act in a preventative capacity, behavioral health organizations need technology infrastructure capabilities (

). States have been awarded planning grants to set up the clinical and technology infrastructures for behavioral health management. But how do we ensure the states are effectively implementing their technologies and clinical workflows?

Creating a set of standard quality measures is a logical step. For example, the standard length of time it takes from call to mobile crisis team disposition could be set to a time interval, based on geography. If a team cannot meet that benchmark, there should be consequences. After all, taxpayers are giving states a lot of money to set up these systems. We need to know they are working. There is simply too much at stake.

is Chief Medical Officer for Appriss Health, co-founder of OpenBeds, and an emergency medicine and critical care physician.

1. The National Council for Behavioral Health. COVID-19 continuing to impact behavioral health organizations in need of relief. Accessed June 29, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2020/09/200903_NCBH_SCR.png

2. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. 

3. Substance Abuse and Mental Health Services Administration. National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. February 2020. Accessed June 29, 2021. 

https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf

4. Everett A. Groundbreaking developments in suicide prevention and mental health crisis service provision. Substance Abuse and Mental Health Services Administration. May 14, 2021. Accessed June 29, 2021. 

https://blog.samhsa.gov/2021/05/14/groundbreaking-developments-suicide-prevention

5. National Suicide Prevention Lifeline. Our network. Accessed June 29, 2021. 

https://suicidepreventionlifeline.org/our-network/

Yes, we need better crisis management, but what we really need is better crisis prevention.

The Need for Better Crisis Prevention

In the past few years, opioids have seen an increase in media attention, as the country grapples with what has been called an opioid epidemic. However, 

 is not just a plague of recent decades; the phenomenon of widespread opioid addiction dates back to the 19th century when the Civil War sparked the United States’ first opiate addiction epidemic among ailing veterans. Nineteenth-century opiate addiction cases usually originated in doctors’ prescriptions, a disturbing parallel with today’s ongoing opioid crisis resulting from opioid overprescribing during the 1990s.

The alarming parallels between the 19th- and 21st-century opioid crises in the United States are not limited to iatrogenesis. Both crises exhibit a history of troubling racial inequalities in access to opioids as well. Addiction was far more common among White Civil War veterans than among Black veterans, who lacked equitable access to opiates. This pattern presaged the opioid underprescribing experienced by Black Americans in recent decades.

 Thus, the history of the Civil War–era opiate addiction epidemic not only reveals the deep historical origins of iatrogenic opioid addiction in the United States, but also underscores how Black Americans have experienced long-standing racial inequalities in access to opioid medicines.

Opioid Use Patterns During the Civil War Era

During the antebellum decades, addiction to rudimentary opiates such as laudanum and opium in gum, pill, and powdered forms was common among White Americans. Discussion of opiate addiction, often dubbed the “opium habit” or “slavery to opiates,” appeared frequently in medical journals, monographs, textbooks, and newspapers beginning in the 1830s. Psychiatrists, physicians, and other Americans widely attributed opiate addiction to the sufferers’ mental illness, constitutional weakness, or moral failings. Consequently, Americans afflicted by this opium habit were frequently victim-blamed, stigmatized, and institutionalized.

In reality, Americans addicted to opiates could usually trace their troubles to medical care. Most opiate addiction in the 19th century was iatrogenic, stemming directly from 

physicians’ prescriptions or their medical advice

 Opiates were standard remedies for hundreds of ailments (

). A survey of 30 antebellum American medical textbooks, materia medica commentaries and formularies, medical handbooks, medical dictionaries, and home health guides published between 1813 and 1858 identified approximately 150 distinct ailments for which opiates were indicated. The figure fluctuates slightly depending on how certain illnesses are classified, as many 19th-century medical diagnoses do not map precisely to modern diagnoses.

 records indicate that opiates were among the most commonly prescribed medicines of the 19th century. In a pre–germ theory era, when typical medical interventions failed to effectively address the microorganisms at the root of many sicknesses, doctors and patients prized opiates as utilitarian remedies that effectively mitigated a legion of symptoms, regardless of cause. Indeed, as one enthusiastic medical student at the University of South Carolina explained, 

opium was “the ‘Magnum Dei Donum’”

—the great gift of God—“of the Materia Medica.”

In the aftermath of the Civil War (1861-1865), the phenomenon of opiate addiction reached epidemic levels for the first time in American history, developing into a major public health crisis with alarming social implications. This epidemic, the earliest opioid crisis in US history, was driven initially by sick and injured Civil War veterans, who became the first distinct cohort in the nation to be widely associated with opiate addiction. The Civil War presented the greatest health disaster of the 19th century. It prompted surgeons to rely more heavily than ever on opiates, including the newly available hypodermic morphine injections.

 A Confederate medical handbook summed up the medical consensus of the day when it described opium as the most “

—important to the surgeon, as gunpowder to the ordnance.”

Accordingly, military surgeons of the North and South prescribed opium pills and morphine injections liberally to ease pain stemming from gunshot wounds, amputations, and traumatic nerve injuries. Surgeons also doled out opium and laudanum to treat dysentery and diarrheal sicknesses, the most common health complaints of the war. Many soldiers, taking their cue from army surgeons, continued purchasing and consuming opiates after leaving the military. This was not terribly difficult because there were few legal restrictions on narcotics until the early 20th century. The Civil War thus sparked an unprecedented surge in iatrogenic opiate addiction, resulting in tens of thousands of cases of chronic addiction among veterans. Predictably, overdose deaths were frequent among veterans, and the medical literature of the period is littered with cases of men whose 

Black Civil War Soldiers and Opiate Addiction

Racial disparities were evident among Civil War veterans addicted to opiates, who were disproportionately White. Although Black soldiers comprised approximately 10% of the US army during the Civil War, they were not equally represented among the cohort of veterans who were addicted. In a sample of approximately 150 Civil War veterans who experienced opiate addiction in their postwar lives—the largest sample of any study to date, albeit compiled from spotty, extant Civil War–era medical records—I could identify only 1 Black Civil War veteran who suffered from an opium habit.

Contemporary physicians and psychiatrists likewise noted a distinct racial gap in opiate addiction. In 1885, a physician reported that the Eastern North Carolina Insane Asylum had admitted an exceedingly rare case of a “colored insane man” of whom “it was alleged that his insanity was caused from the opium habit.” The man’s case was worthy of note because “this was the only case of opium habit he [the doctor] had ever seen in the negro.”

 The next year, a White Alabama physician also observed that “the opium habit is rare” among the Black population after the Civil War.

Surveying the records of morphine maintenance clinics that dotted the United States from the 1910s to the 1920s, historian David Courtwright observed that the Southern White population experienced the highest rate of opiate addiction in the nation. 

in the clinics’ records, although the facilities were ostensibly open to Black patients.

This enduring racial gap in the opiate addiction rate stemmed largely from racist 19th-century medical beliefs about Black bodies, coupled with substandard medical care provided to Black Civil War troops. Nineteenth-century psychiatry posited that, among other causes, opiate addiction stemmed from mental overstimulation, which led to insanity and substance abuse. Such overstimulation could only occur among intelligent, sensitive White Americans, according to Civil War–era psychiatrists. In contrast, White medical authorities claimed that Black Americans were too “simple-minded” to experience mental overstimulation, which precluded them from 

According to J. D. Roberts, a North Carolina doctor, Black bodies lacked “the same delicate nervous organization” as Whites, and thus “d[id] not demand the form of stimulant conveyed in opium” as did Whites. Black people, Roberts claimed, also had a “general ignorance” of medical care, an assertion implying that Black Americans lacked the knowledge to care for their health needs by self-medicating with opiates, as White Americans often did.

This constellation of racist beliefs was developed by antebellum White Southerners to justify keeping Black people enslaved and to ward off abolitionist critiques.

 After the Civil War, apologists of Jim Crow fine-tuned these beliefs and used them to explain why White Civil War veterans had opiate addiction more often than Black veterans.

In reality, the relative infrequency of opiate addiction among Black Civil War veterans and other African Americans during the late 19th century stemmed from structural racism in medicine and health care. Undertreatment for pain and subpar medical care in the military left Black veterans far less likely to become addicted to opiates than their White counterparts. Just as White doctors believed that Black Americans were less liable to mental overstimulation than White Americans, so too did these physicians believe that Black bodies were less sensitive to pain.

 Consequently, Black Americans were much less likely to be prescribed opiate painkillers during the Civil War.

The enduring racial gap in the opiate addiction rate stems largely from racist 19th-century medical beliefs about Black bodies, coupled with substandard medical care provided to Black Civil War troops.

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