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Approximately, 775,000 US Armed Services members served at least 1 deployment in Afghanistan; a new survey of 1250 of these 

 found that 70% of them have struggled with their mental health since serving in Afghanistan.

“Trauma can alter how people think about themselves, others, and the world,” said clinical counselor Danny Taylor, MA. “The current situation in Afghanistan is a painful reminder of the traumatic experiences service members may have had in Afghanistan. This can lead to ideas that nothing is safe, and no one can be trusted.”

According to the survey, 75% of Afghanistan 

 are experiencing new or worsening symptoms of depression, 74% have new or worsening outbursts of anger, 64% have new or worsening thoughts of suicide, and 58% have started or increased drug and/or alcohol use.

Additionally, a third of veterans with a history of mental illness have started seeing a mental health professional since the Taliban retook Afghanistan in mid-August.

Holly Schiff, PsyD, believes the decline in veteran mental health may be triggered by feelings of powerlessness or fear about the situation in Afghanistan: “Veterans are usually looking for meaning and how the conflict ends definitely holds some significance. These individuals made enormous sacrifices and the fall of Afghanistan had them reflect on if everything they did was worth it. This can lead to feelings of depression and anger.”

The fall of Afghanistan may also be triggering new or worsening thoughts of suicide in 64% of veterans coping with mental illness. Researchers reported 32% are experiencing new thoughts of 

, while another 32% indicate their suicidal thoughts have grown worse in the past few weeks.

“I have absolutely seen an increase in patients who are veterans since the fall of Afghanistan,” Schiff said further. “This makes sense given the fact that this situation may trigger unresolved issues or past traumas that they now have to address and deal with all over again.”

“The fall of Afghanistan definitely triggered some mental health issues for Afghan vets, some of which will have potential long-term effects and consequences,” Schiff told 

. “For those veterans already struggling with posttraumatic stress disorder, the fall of Afghanistan brought back up some unresolved issues for them, past traumas and some unpleasant thoughts, feelings, and experiences. They now have to address these and almost re-process them for a second time.”

 is an endless war, but the current events just made it worse,” she added. “They may feel anxious, depressed, angry, helpless, frustrated, and sometimes even experience suicidal ideation. Longer-term, some of these veterans may feel like some old wounds were re-opened with this event and it will take them some time to recover and process the range of emotions that they are now feeling. In reaction to the events in Afghanistan, veterans may feel like they need to expect or prepare for the worst. This can have long-lasting impacts as it may alter their behavior and moving forward, they may become overly vigilant, guarded and become preoccupied by danger.”

To see more on Afghanistan’s impact on mental health, check out 

Psychiatrists Concerned With the Afghanistan Situation: Ethical and Practical Issues

Have ideas on how to best serve the veteran mental health community? Share with us 

1. Following Taliban takeover, 9 in 10 Afghanistan vets have exacerbated mental health symptoms. Online Therapy. Accessed September 8, 2021. 

https://www.onlinetherapy.com/taliban-takeover-exacerbates-vets-mental-health-symptoms/

A recent survey found 70% of Afghanistan veterans have struggled with their mental health since serving. 

Afghanistan Veterans Struggling With Mental Health

 Tales of the Clinic: The Art of Psychiatry

, we discuss a patient who was construed as difficult to manage by multiple standards and elicited strong feelings from the treatment team. Ms Grant is a 29-year-old female with a history of alcohol use disorder (AUD) and complicated alcohol withdrawal. This case presentation spans 4 years and highlights the importance of behavior shaping and personality trait management to achieve stability. The focus is treating patients who are at risk of being perceived as “less than likeable, disruptive, and uncooperative.”

, Ms Grant describes her life as wrought with chronic anxiety and depression, with a frequent desire to self-medicate with alcohol. Her story includes multiple rehabilitation programs, inpatient psychiatric hospitalizations, and suicide attempts in the context of alcohol use. Borderline and antisocial traits seemed to influence her clinical presentation. She became well-known to the clinic and hospital staff for one incident that involved her throwing a shoe directly at a police officer’s face.

Social and family history was significant for intergenerational 

, involving her mother, father, and maternal grandfather. Ms Grant relates fond memories of her father, yet reports a childhood dominated by physical abuse and neglect, with the notable absence of her mother. She struggled in school and had suspensions and behavioral problems. Ms Grant became pregnant at 17 years of age and dropped out of school. Her partner left during her pregnancy, so she had to stay with her father.

Substance use and psychiatric history started early, with her first drink during her high school freshman year. She describes peers and boyfriends, whom she shared drinks with, as the support system she never got from family. She abstained from alcohol with her first pregnancy but developed postpartum depression and relapsed when her child turned 5 months old. The stressors of raising her child alone exacerbated feelings of 

. Family support was limited, and her romantic relationships did not last long because of alcohol-associated behaviors. Ms Grant had her second child at the age of 20 while in a verbally and physically abusive relationship. Child protective services were involved. When she was 26, her two children were taken away and placed under a cousin’s care; the relationship ended as well.

Her treatment course included striking, intense episodes of intoxication with agitation and suicidality. One involved being verbally aggressive towards employees and customers while intoxicated at a gas station. In the emergency department, declarations of suicidal ideations, a blood alcohol level > 300 mg/dl and a history of complicated withdrawals led to inpatient hospitalization. She was discharged back to outpatient care, having consistently denied suicidality when no longer intoxicated, and declined transfer to a rehabilitation program at the time.

The second incident involved being caught stealing a wallet from another patient in the clinic. Ms Grant denied the theft despite confrontation, so police were called. The police asked to search Ms Grant’s backpack, but she escalated, cursed, and swung at the officers. This led to a physical scuffle in the psychiatrist’s office, that ultimately culminated in Ms Grant sustaining scratches and bruises. She was handcuffed, brought into police custody for refusing to comply with the search, and subsequently charged and incarcerated for a week.

The psychiatrist felt ongoing empathy for the patient struggling with anxiety and alcohol use disorder who had no one else for support. At the same time, it was a difficult decision on whether to continue treatment following the 

. Despite a strong desire to maintain a working relationship that had lasted for years, there was a sense of disappointment, and even anger, towards the dishonest and illegal behaviors that directly affected other patients. There were concerns about the potential for further covert theft or altercations if she were to continue treatment in the clinic. In addition, the psychiatrist had vivid, uncomfortable memories of the office scuffle.

Yet, Ms Grant, just like many with co-occurring disorders, was at very high risk of acute decompensation with perceived abandonment, which cessation of treatment would have been to her. The psychiatrist considered evaluating the decision-making process from a harm-reduction approach. If Ms Grant were to no longer receive treatment in the clinic, she would likely decompensate, with possible increases in aggressive, antisocial behaviors, and substance use. The psychiatrist felt sharing and processing this case with other colleagues was helpful, especially regarding countertransference.

Another consideration was that Ms Grant, as a woman, faced unique challenges to obtaining substance use treatment. 

Women are less likely to seek treatment for AUD

, and multiple barriers have been identified among women compared to men, including gender stereotype roles and societal expectations, even though women are more predisposed to medical complications from alcohol use.

 Women face gaps in employment, economic challenges, and more parental responsibilities compared to men.

 Along with logistic barriers to treatment including transportation issues, limited childcare resources and insurance, and fear of losing children to child protective services, women are more likely than men to attribute alcohol use disorder to character flaws rather than to genetic disposition.

 With these pressures and beliefs, the fact that women have lower rates of substance use treatment compared to men is unsurprising.

Fortunately, recent research indicates that the gender gap of AUD has been narrowing,

 with studies indicating higher satisfaction in women-only treatment programs. Ongoing challenges include limited access to these types of programs and the necessity of further research to identify the effects on engagement and response to treatment.

Ultimately, considering all these factors, the psychiatrist decided to allow Ms Grant to continue clinic treatment, despite reservations from the clinical staff. They worked through these feelings of anger towards Ms Grant, which was helpful not only for a sense of closure for the psychiatrist and to help promote setting treatment boundaries, but also to help Ms Grant identify the consequences of her actions through behavioral chain analysis. It also helped to visualize that despite all that had happened, Ms Grant was doing “the best that she could,” relying on her limited coping skills, unfortunately stunted by 

. This step is essential to avoid judging the patient from a moral standpoint, where maladaptive or disruptive behaviors are viewed as entirely volitional. With this approach, work was able to resume, with her goals largely revolving around maintaining employment to regain custody of her children, and maintaining her current relationship.

The treatment team and Ms Grant’s deeper understanding of her own motivations and 

 served as a catalyst towards treatment adherence and sobriety. She had chronic difficulty trusting and building new relationships, including those with mental health providers. This issue could be compounded by the concept that patients with substance use disorder (SUD) and personality disorders have often encountered judgmental stances and behaviors, even if subtle or unconscious, from healthcare providers. Bias against patients with SUD, legal histories, and personality disorders can occur easily, especially when the patient is perceived to be “behaving badly.”

Organizationally, clinics are rarely set up with enough support to manage severe personality pathology and navigate psychosocial stressors stemming from complex addiction histories. As the development of AUD is complex and multifactorial, treatment is variable and has to incorporate multiple contributing factors including psychological factors, genetics, personality traits, traumatic events, and family dynamics.

 Research indicates some benefits of regular attendance of Alcoholics Anonymous meetings, but this may not be a treatment that works for everyone.

 Project MATCH, sponsored by the National Institute on Alcohol Abuse and Alcoholism compared 3 different types of therapies and found some positive results with each therapy modality, implying that multiple therapeutic approaches can be utilized in addition to medications.

Support for treating physicians and therapists is essential, as patient relapses and failed treatment trials can contribute to feelings of helplessness, anger, and frustration for both patient and treatment provider

 Identifying this in our own self, as well as any subconscious biases, may provide the space to combat the reactions that come with our countertransference and redirect attention towards meeting the patient’s needs

On a biological level, typologies and classifications have been developed to further classify the development and presentations of 

. Ms Grant’s family history, early onset of alcohol use, and history of legal problems correspond with Cloninger type II alcoholism, which has increased genetic predisposition compared to type I.

Cloninger type I alcoholism is typically associated with adult-onset and harm-avoidance behaviors. Differences in personality traits may underscore drinking motivation; type I alcoholism associates alcohol use with anxiety reduction, while type II corresponds to sensation-seeking behaviors. Neurobiological differences between alcoholism subtypes (serotonin levels, monoamine oxidase activities) are also known. However, the type II subset, under the Stockholm study, was found more commonly in men compared to women, whereas type I affects both genders equally. Identifying topology helps clinicians conceptualize a patient’s presentation, anticipate treatment needs, and may help guide medication selection. For example, off-label use of ondansetron works better for early-onset.

 Patients treated with sertraline may respond better if they have less severe AUD.

Personalized treatment plans work best and should include medication in conjunction with psychotherapy. Naltrexone has the benefit of different routes of administration; intramuscular formulation leads to improved compliance/better outcomes compared to oral. Acamprosate, a hepatically safe option, can help increase time to relapse; however, 3 times daily administration may deter adherence. Disulfiram, an example of aversive therapy, can provide physical discomfort to curb drinking, but effectiveness is limited by poor compliance and risk of induced hepatitis/psychosis. Of note, Ms Grant had already tried all of the FDA-approved options for AUD treatment with little success or tolerability.

Thus, off-label medication was considered. Off-label medications for AUD mirror our understanding of the neurobiology of alcohol use. Varenicline (effects on nicotinic acetylcholine receptor), baclofen (GABA receptors), and ondansetron (serotonin 5-HT

 receptor antagonist), are just a few of the many suggested potential treatments given the complex effect of alcohol on the neural pathways.

 Ms Grant was eventually started on topiramate as further studies report improvement of drinking outcomes and quality of life with adjunct therapy with topiramate compared to placebo.

 The addition of topiramate, with an off-label indication, helped reduce Ms Grant’s cravings and days of heavy drinking. The risks of inadequate treatment of AUD, including frequent rehospitalizations, emergency room visits, and further hepatic injury from drinking, were considered much more dire than off-label potential side effects.

The efficacy of selective serotonin reuptake inhibitors for cravings has been sparse, and use for AUD does not follow American Psychiatric Association guidelines; however, studies have also indicated that patients with mental health conditions are more vulnerable to substance use. It is not uncommon to have a comorbid mental health disorder and substance use. Depressive and anxiety symptoms can also stem from alcohol use.

In addition, research indicates that the chronic use of alcohol, repeat periods of abstinence, and withdrawal results in changes in the prefrontal–striatal–limbic (PSL) circuit, which plays a significant role in emotion regulation, decision making, and modulating reward and stress.

 Therefore, the role of antidepressants on serotonin may have potential effects on obsessional thoughts and impulsivity with chronic alcohol use.

 Open discussions with patients regarding current availability of medications and setting realistic expectations of the effects of medications may mitigate the frustrations arising from continued cravings, a common complaint in SUD patients, and counteract the belief that medications alone lead to remission.

When a patient walks out of the office, one question lingers, 

? This may especially be the case in AUD treatment. AUD is complex, multifactorial, and treatment includes taking into consideration biological, psychological, and socioenvironmental factors. We must gently process and elicit the details of one’s life that they might be the most shameful of, in order to address the deeper underlying issues. Identifying our own defenses and countertransference can potentially improve the therapeutic alliance. The presence of personality disorders can also provide an additional challenge while balancing limited resources and constraints a patient may also have that prevent them from utilizing these options. Thankfully, in addition to off-label options, there are 3 FDA approved medications to treat AUD, though they remain woefully underused. 

There are many patients with stories like Ms Grant; however, with prodding, patience, and exploration, positive outcomes can be achieved. Lastly, systemic and organizational structures ought to take into account the complex treatment needs for SUD, and thoughtfully target resources.

Three years after the office scuffle, the outlook has been much brighter; Ms Grant has found stable and supportive housing and has been in remission from alcohol use for the past 2 years. She lives with her husband and cat and attends online 12-step groups. She clearly recalls the struggles she went through during treatment and uses that to prevent her from drinking again. While her past struggles may have been a reason to abandon hope, she is grateful that neither she, nor her psychiatrist, gave up. Her psychiatrist also realizes that while complex cases can be challenging, they also include the most meaningful work and lead to the most personal growth and satisfaction.

psychiatry resident at the Baylor College of Medicine.

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.

1. Agabio R, Pisanu C, Luigi Gessa G, Franconi F. 

Sex difference in alcoholism: who is at a greater risk for development of alcoholic complication?

3. Epstein EE, Menges D. Women and addiction. In: McCrady BS, Epstein EE (eds). 

4. Lale R, Sklar M, Wooldridge J, Sarkin A. 

Gender congruence moderates beliefs about the causes of alcohol dependence and major depression.

Treatment interventions for women with alcohol use disorder.

Psychodynamic psychiatry in Clinical Practice

7. Cloninger CR, Sigvardsson S, Bohman M. 

Type I and type II alcoholism: an update.

8. Johnson BA, Roache JD, Javors MA, et al. 

Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial.

Sertraline in the treatment of co‐occurring alcohol dependence and posttraumatic stress disorder. 

Anticraving therapy for alcohol use disorder: a clinical review.

11. Johnson BA, Ait-Daoud N, Akhtar FZ, Ma JZ. 

Oral topiramate reduces the consequences of drinking and improves the quality of life of alcohol-dependent individuals: a randomized controlled trial.

Neuroplasticity and predictors of alcohol recovery.

Treating patients who may be perceived as “unlikeable” can be difficult. 

To Treat or Not to Treat? The Conundrum of Likeability

In many ways, September is a time of changes and new beginnings. Children return to school, a little bit older and wiser and ready for new learning adventures. A new season arrives and promises comfort and coziness—apple picking and apple cider, beautiful autumn leaves and oversized blankets, and the hint of the holidays right around the corner. Similarly, there is the Jewish New Year, which also marks sweet new beginnings and opportunities.

September also marks some somber moments. The delta variant has increased the number of COVID-19 cases. Just as we were making progress, we seem to be fighting a new battle on that front. This month is also the 20th anniversary of the September 11th tragedies. As James Knoll IV, MD, reminds us in this issue, the anniversary both allows for reflections on the past and offers an opportunity to do better in the future. He eloquently speaks of the 3 antidotes to these tragedies: compassion, compromise, and creativity. By following these ideals, we can seize control, march forward, and make a positive impact in medicine and our communities.

Interestingly, that is exactly what Tony George, MD, and colleagues suggest in addressing the opioid crisis. Investigating harm-reduction programs that have been successful in Canada, the authors consider how these programs might be implemented in the United States. The second part of our Special Report on Minority Health similarly explores creative ways to connect with underserved populations. Throughout the issue, you will find articles sharing clinical advice and insights to support you as you aim to help your patients.

With that in mind, we hope you will continue to turn over a new leaf—and the pages of 

—as we look ahead to new adventures and new successes! ❒

As the seasons change and new possibilities open up, we also pause to remember the victims of September 11 and the ongoing opioid crisis. 

Turning Over a New Leaf

 has progressed during the past 2 decades, more and more patients have left their doctors’ offices with prescriptions for benzodiazepine medications (BZDs). Across the medical profession, the percentage of outpatient visits resulting in a BZD prescription has increased from 3.8% in 2003 to 7.4% in 2015.

 It is estimated that concurrent use of BZDs and opioids may occur in as many as 50% of 

 This shocking statistic suggests the possibility that more cautious and conservative use of BZDs by all who prescribe them has the potential to save thousands of lives per year. 

During the time period studied by Agarwal et al,

 outpatient psychiatrists manifested a stable pattern of BZD prescribing, delivering BZD prescriptions to the patient in 30% of psychiatric visits. Overall, BZD prescriptions written by psychiatrists account for approximately one-sixth of the more than 25 million prescriptions that are written each year.

 In the years 2015 and 2016, 30.6 million US adults reported BZD use in the past year; of these, 5.3 million were deemed to be misusing BZDs.

 The most common type of BZD misuse occurs when prescribed BZDs are diverted and utilized by individuals who are not receiving them for a legitimate medical indication. 

These threads of data suggest that some BZDs prescribed by psychiatrists end up being misused by individuals who are also misusing opioids, and that some of these 

opioid overdose deaths are potentiated by BZDs

 prescribed by a trusting psychiatrist. Are these BZDs that originate in mental health settings a factor in hundreds of yearly opioid overdose deaths, or in thousands? Although the magnitude of this problem is not known, it is likely that psychiatrists who exercise more caution in prescribing BZDs can play a role in doing less inadvertent harm.

 performed a comprehensive review of studies on the combined use of opioids and BZDs. They concluded that “that the co-abuse of opioids and BZDs is ubiquitous around the world,” that BZDs are utilized by many opioid abusers to potentiate opioid intoxication, and, that the co-abuse of opioid and BZDs “has negative consequences for general health, overdose lethality, and treatment outcome.”

Perhaps their 2012 conclusion that physicians should exercise more caution and vigilance in prescribing BZDs is reflected in the fact that psychiatrists have paid attention, and not increased our rate of BZD prescribing. Whereas psychiatric BZD prescriptive practices have remained stable, other physicians, especially primary care providers, are delivering nearly twice as many BZD prescriptions to patients.

 However, in view of the subsequent progression of the opioid crisis and the mounting overdose death toll, reducing the rate of BZD prescriptions in psychiatric practice may indeed be a worthwhile, life-saving consideration.

 suggest that by adhering to universal precautions in pain medicine, physicians are able to routinize a cautious, non-stigmatizing clinical approach that facilitates their ability to limit opioid prescriptions. It would likely be helpful for psychiatrists to adopt a parallel set of best practices and universal precautions with regards to prescribing BZDs and other psychoactive pharmaceuticals with abuse liability. Gourlay’s original 10 universal precautions can be found in the 

 for a list of 8 universal precautions adapted from Gourlay et al

 for use by psychiatrists faced with the decision to initiate or continue pharmacotherapy with BZDs.

Epidemiological studies suggest that individuals with untreated anxiety and mood disorders may be prone to self-medicate with nonmedical use of opioids. Use and misuse of opioid drugs may themselves aggravate symptoms of anxiety.

 It is not surprising, then, that outpatient psychiatrists sometimes provide BZD prescriptions to patients who may covertly be suffering from 

. As substance use disorders (SUDs) have long been associated with behaviors that may be deemed antisocial,

 and one such behavior is deceptive communication,

 community-based psychiatrists in high-volume clinic settings may be at risk of being fooled by drug-seeking patients.

The ease of integrating some or all of the 8 suggested universal precautions for initiating or continuing BZD pharmacotherapy will vary from treatment setting to treatment setting. At the very least, this aspirational list of precautions may facilitate the ability of mental health professionals to offer a clinically sound integrated approach for the treatment of co-occurring psychiatric and SUDs. Integrated treatment of co-occurring disorders is the accepted standard of care for this challenging, high-risk patient population.

a coaching and consulting psychiatrist, and is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched

after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

Patterns in outpatient benzodiazepine prescribing in the United States.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.

Benzodiazepine use and misuse among adults in the United States.

Polydrug abuse: a review of opioid and benzodiazepine combination use.

Universal precautions in pain medicine: a rational approach to the treatment of chronic pain.

6. Martins SS, Fenton MC, Keyes KM, et al. 

Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions

Natural history of male alcoholism V: is alcoholism the cart or the horse to sociopathy?

Common and challenging behaviors among individuals on long-term opioid therapy. 

Integrated treatment of substance use and psychiatric disorders.

Are benzodiazepine prescriptions contributing to the opioid overdose epidemic? 

The Case for Caution When Prescribing Benzodiazepines 

In 2016, drug-related overdoses became the 

 with opioids as the primary culprit. Although significant state-by-state variability exists, with some geographical areas impacted more than others, 

opioid-related overdose deaths have been a national epidemic

 with the death rate at historic highs in the first quarter of 2021.

 Aside from federal legislative efforts, states have independently implemented policies and deployed resources to address this issue. Interestingly, some states that had high overdose deaths in 2016 experienced a drastic decline in 2017 upon implementation of prevention and response efforts. In this article, the authors qualitatively examine the efforts of these successful states and look for 

 What are the core elements of overdose prevention and response activities in states with high rates of opioid-related overdose deaths that experienced a decrease in overdose deaths from 2016 to 2017?

 Retrospective qualitative thematic analysis of successful states’ overdose prevention programs based on predetermined categories to organize their activities.

: Individuals from Massachusetts, New Hampshire, New Mexico, and Utah who died by opioid-related overdose from 2016 to 2017 and who have been reported to the Centers for Disease Control and Prevention (CDC)’s Wide-ranging Online Data for Epidemiological Research.

: Mortality data from the CDC was used in identifying the 25 states with the highest age-adjusted opioid-related overdose mortality rates in 2016. Only the 4 states that experienced a decrease in age-adjusted mortality rates from 2016 to 2017 were selected for analysis. The authors then used data from the 4 states’ progress reports (generated for the CDC as condition of their funding), to identify overdose-related programs and their outcomes. This was supplemented by an environmental scan of websites and other strategic planning documents to further capture information on overdose prevention and response. Three of the authors then compiled draft program narratives summarizing their findings. Ten predetermined categories developed according to the 3 authors’ reviews and supplemented by CDC’s recommended prevention strategies were used to organize activities implemented by each of the 4 states. For each of the states, overdose program implementers were also tasked to review the draft program narratives to ensure accuracy and comprehensiveness. Data regarding historical progression of some of the efforts pre-2016 was also considered.

 The 3 authors performed a systematic content analysis of the completed program narratives using an iterative thematic approach to coding to elucidate prevention activities and to generate hypotheses for further research. Analysis used the organizing categories as the first level in the hierarchical coding framework. The authors distilled descriptions of each activity in a category into thematic codes to identify common themes across multiple program narratives, which were then used to identify activities implemented by all 4 states (dubbed “core activities”). Additionally, thematic codes that did not occur across all 4 programs narratives yet were believed by the 3 authors to exemplify approaches tailored to the local content were used to identify context specific activities (“additional elements”).

 From the predetermined categories, the following core elements of overdose prevention and response were identified: comprehensive state policies; strategic planning; local engagement; data access, capacity, and dissemination; targeted training for professional audiences; treatment infrastructure; and harm reduction (

The authors also developed a list of additional elements that some states utilized. These includes ways to handle populations with needs uniquely specific to the area (rural communities, homelessness, ethnic/minorities such as Hispanic or tribal populations, diversion/drug courts). All 4 also described various approaches to public awareness through campaigns specific to the local context and hotlines for access to resources. Although the approaches differ, they all focus on linkage to treatment resources (ie, the hub-and-spoke model in New Hampshire or the peer support and coaches in New Mexico and Massachusetts).

 serves as a valuable opportunity to understand how states can be successful in their efforts towards overdose prevention and response. The authors identified comprehensive state policies, strategic planning efforts, local engagement, data collection and dissemination, targeted training for professional audiences, treatment infrastructure, and harm reduction, as the core elements of overdose programs in states that experienced a decline in the rate of opioid involved overdose deaths from 2016 to 2017. These elements contribute to successful overdose prevention and responses, and such activities can be extrapolated to other public health crises beyond just the opioid overdose epidemic, especially as new drug threats emerge. 

 This study represents an attempt at elucidating the core elements of successful 

 and response programs. These can broadly help states consider new policies, partnerships, and activities to enhance their own programs against the current, and future, overdose deaths. Comprehensive policies, timely dissemination of key data, and building capacity through training, treatment infrastructure, and harm reduction activities are prevention efforts shared by the 4 successful states; however, each state tailored its programs to its own context, with emphasis on the needs of the target population. These elements are also enmeshed by partnerships and collaborations among various segments of the public health response and public and private sectors. The 4 states had robust foundations of multifaceted policies (ie, Good Samaritan laws, PDMP access, and policies to enhance naloxone distribution) which preceded the development of programmatic efforts.

In addition, all 4 states also had comprehensive strategic planning at both state and local levels in the form of commissions, workgroups, and advisory committees. Another common theme was the local engagement by state health departments, which facilitated support and capacity building via technical assistance (implementation and evaluation of prevention activities, using data to inform interventions, and disseminating evidence-based data to inform interventions). Aggregating data also allowed for targeted identification of populations disproportionately affected and interventions. Training pharmacists, law enforcement, and other professional audiences as well as using harm reduction activities (such as syringe and naloxone distribution) were also strong building blocks.

It is important to note that all 4 states evaluated received opioid-focused funding from the CDC, as well as from other federal and nonfederal sources, in order to implement prevention and overdose reduction strategies, and/or to improve overdose data collection.

The question is, are these findings generalizable to other drug related overdose deaths or epidemics? This is one of the limitations—yet of importance given that we are currently also dealing with a quiet 

 The 4 states had program narratives that included description of drug overdose more broadly, beyond just opioids, which is reassuring. 

Applicability to overdose prevention programs in other states

. It does not address whether states that did not see a decrease in opioid related mortality shared the same core elements in their overdose prevention programs with those states that did. This information is necessary to determine both the importance of certain core elements when it comes to decreasing mortality and the applicability of these core elements in other states. If other states were found to have implemented the same core elements and failed to see a decrease in opioid overdose mortality, it would limit the external validity of this study.

. The scope of the study was focused on states with decreased opioid overdose mortality from 2016 to 2017. However, it should be asked whether the states involved in the study experienced a plateau or a further decrease in their opioid overdose mortality in subsequent years. If a state involved in the study was found to have an increase in their opioid overdose mortality in subsequent years, it may indicate that the drop in deaths from 2016 to 2017 was a natural fluctuation. Additionally, it would bring into question the possible correlation between decreased overdose mortality and the implementation of the core elements identified.

The selection of states investigated in this study is not fully explained in the methods section

. It was not discussed how the 4 states with decreased overdose mortality were selected from the 25 states with the highest mortality rates that were included for consideration. Additionally, the paper fails to identify the absolute or relative decrease in overdose mortality that the included states experienced. Although this is separate from the main goal of the paper, this information could be pertinent to how the findings may be interpreted. If one of the included states experienced a decline of 20 opioid deaths from 400 deaths in the previous year, this would be a 5% decline but may be more likely a product of variability and less likely related to the implementation of the core elements discussed due to the low change in absolute mortality.

Variability between states in reporting opioid-related overdose deaths to the CDC

. Because of this, the death rates used to identify the 25 states with high rates of opioid overdose mortality and those 4 states who saw a decrease in opioid overdose mortality from 2016 to 2017 may be underreported in some states more than others. More information on how these states, especially the 4 with decreased opioid overdose mortality, report deaths to the CDC could support the finding that mortality decreased in these states and was not a result of underreporting. This variability exists because states have different policies and capacities for postmortem testing. For example, some state laboratories may not evaluate the deceased for synthetic opioids, like fentanyl, or may avoid toxicology screens altogether in certain situations. Another possible confounding factor revolves around the reported cause of death. Some opioid related overdose deaths may not be reported to the CDC as an overdose, but instead could be reported as a related cause like anoxic brain injury. Given interstate variability in reporting, it may be pertinent to acknowledge how the 4 states identified in this study report their opioid overdose deaths to the CDC and how this reporting compares to the other 25 states with high rates of opioid overdose mortality.

The paper does not detail how the 10 categories they used to organize activities in overdose prevention program narratives were determined.

 It mentions that categories were developed by the authors’ review of data obtained by the preliminary environmental scan and informed by CDC’s recommended evidence-based prevention strategies, but it does not explain further how the authors came to the conclusion to use the 10 categories listed. Given that the 7 core elements are derived from these 10 categories, it would be relevant to address how the authors decided upon them. This would provide readers with better insight into this study and could serve to validate the choice of the 10 categories.

This study mentions that only activities with opioid-related CDC funding were included and that separate nonfederal and federal non-CDC donations may have been made that were beyond the scope of the study

. Such donations, however, could have had a substantial impact on additional activities in the states that experienced a decrease in overdose mortality. Although the purpose of the study was not focused on attributing changes in overdose mortality to any particular funding, choosing to ignore these other sources may influence what activities were identified as the most prominent or impactful, since only a subset of activities is being investigated. Even within the states included in the analysis, authors state that CDC funding varied with 3 states receiving funding for both implementing prevention strategies and improving data collection, while New Hampshire only received funding to improve data collection. Identifying if the states being investigated had additional funding, and how this funding compared to the funding in other states, would be relevant to interpreting the results of this study. If states were working with similar amounts of funding, it would detract from the number of possible confounding factors in this study. If funding was not similar across states, it still may be pertinent to compare the states that had decreased opioid-related overdose mortality from 2016 to 2017 to other states that did not experience a decrease but who had a similar amount of funding. This could help either elucidate more core elements or strengthen the argument for those identified in this study.

Despite the limitations, this is an important study with the data providing valuable insight. Since the beginning of the COVID-19 pandemic, overdose related deaths are once again on the rise with a 20% increase noted in the 12-month period ending last June. The 4 states evaluated here interestingly sustained much 

lower numbers of deaths compared to the national average

is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for

is a fourth-year medical student at Dartmouth’s Geisel School of Medicine who rotated through the Addiction Services at New Hampshire Hospital, Concord, NH.

Increases in drug and opioid-involved overdose deaths—United States, 2010-2015.

 National Center for Health Statistics. 2021.

A thematic analysis of overdose prevention and response efforts in states experiencing declines in rates of opioid-involved overdose deaths. 

Trends and geographic patterns in drug and synthetic opioid overdose deaths—United States, 2013–2019.

5. Baumgartner JC, Radley DC. The spike in drug overdose deaths during the COVID-19 pandemic and policy options to move forward. March 25, 5021. Accessed August 12, 2021. 

https://www.commonwealthfund.org/blog/2021/spike-drug-overdose-deaths-during-covid-19-pandemic-and-policy-options-move-forward

In this journal club, a medical student and an addiction psychiatrist review a thematic analysis of successful prevention efforts in states with declining rates of opioid-related overdose deaths. 

Reducing Opioid-Involved Overdose Deaths: States’ Prevention and Response Efforts 

, a wholly owned subsidiary developing Salvinorin A (SalA) to treat a variety of mental health disorders. SalA, a unique non-nitrogenous agonist of the kappa-opioid receptor (KOR), is derived from Salvia divinorum.

SalA has a complex pharmacological profile. It is an atypical KOR agonist, and its mechanism of action (MoA) shows no interaction at the 5-HT2A serotonin receptor—the main molecular target for hallucinogens like psilocybin.

“Due to SalA’s short psychedelic effect, it will be an attractive option for those who would like psychedelic treatment but are unwilling or unable to participate in longer sessions,” said Glenn Short, CEO of Revixia. “The shorter experience will allow for more practical administration and monitoring, which may even make it possible to attend psychotherapy sessions on the same day.”

Salvia divinorum has been traditionally used by the Mazatec people in Oaxaca, Mexico for a variety of illnesses, such as diarrhea, headaches, and rheumatism, as well as for palliative care. It also has potential use with treatment-resistant depression (TRD), substance use disorder (SUD), and pain.

Published reports suggest potential benefits of Salvia divinorum in the treatment of TRD. One doctor reported on 7 patients with TRD who described relief from depressive symptoms with 

triweekly oral consumption of salvia leaves

. Several patients reported lasting benefits from their use of salvia, with significantly reduced scores on quantitative measures of depression. Patients also reported benefits like mood enhancement, increased feelings of relaxation, and increased self-awareness.

"While SalA has until now been understudied, its unique MoA may allow for combination with SSRIs, potentially giving patients a better chance in beating depression," Srinivas Rao, CSO and cofounder of atai Life Sciences, said to the press. “We’re thrilled to be pursuing SalA and progressing research, as we strive for new treatments.”

Revixia’s product will be paired with a digital therapeutic developed by atai company, Introspect Digital Therapeutics. The company hopes this pairing will streamline preparation, integration, and continued patient engagement.

“In exploring SalA, Revixia aims to develop a product with a differentiated pharmacological and treatment effect. Considering the significance of prior evidence in humans in parallel with the substantial unmet need in TRD, we believe Revixia has high commercial potential and an increased probability of success in the clinic,” Florian Brand, CEO and cofounder of atai Life Sciences, said. “SalA is a great product candidate that magnificently matches the criteria we strive for, with recognized synergies across the atai platform.”

Clinical trials are expected to begin in the second half of 2022.

1. atai Life Sciences. atai launches Revixia Life Sciences to develop Salvinorin A for a variety of mental health conditions. News release. August 12, 2021. Accessed August 13, 2021. 

https://ir.atai.life/news-releases/news-release-details/atai-launches-revixia-life-sciences-develop-salvinorin-variety

2. Hanes KR. Salvia divinorum: clinical and research potential. 

A kappa-opioid receptor with psychedelic effects, this potential agent for treatment-resistant depression and other disorders will be paired with a digital therapeutic for maximum efficacy.

Developing a Novel Psychedelic: Salvinorin A

Tales From the Clinic: The Art of Psychiatry,

 we cover an intriguing case of dual substance use super-imposed on mood, anxiety, and trauma clinical picture. A significant challenge for this group of patients is the need for patient, methodical, consistent care to unravel the complex multifaceted triggers and perpetuating factors for continued maladaptive behaviors. The case description spans years of treatment and, while the details may seem sensational, they reflect the reality of what the addiction treatment clinic team encounters. In addition, there is much difficulty in hearing and processing patient accounts of trauma, which could lead to physician burnout.

“Ms Martin” is a 45-year-old female with bipolar disorder, generalized anxiety disorder, and suspected borderline personality disorder. She was transferred to the substance use disorders clinic by another psychiatrist after a diagnosis of opioid use disorder was obvious. At the time of her transfer, she was involved in prostitution to finance her roughly 25 tablets of acetaminophen and hydrocodone daily. Her opioid use disorder history had a protracted course, with her first exposure to prescription opioids at the age of 16 following a significant injury requiring surgical intervention. Her longest lifetime period of sobriety was 2 years.

Her immediate environment was not conducive to recovery, as she lived in a trailer with a male roommate who had mutual acquaintances that provided pain pills. In addition, Ms Martin engaged in sexual activity with the roommate in exchange for opioids. As time progressed, the relationship became physically abusive; she left after her roommate tried to hit her with a vacuum cleaner when she “didn’t do a good job cleaning the trailer.” At the time, she had been in treatment for 1 year, was started in medication-assisted therapy (MAT), and had been prescribed buprenorphine. She moved into an apartment with her mother, which greatly reduced access to opioids. She responded very well to MAT, with an absence of significant relapses as evidenced by the drug screenings during her monthly visits.

Three years into treatment, Ms Martin met a new boyfriend. Her urine drug screen (UDS) resulted positive for amphetamine. He provided her with substances that boosted her energy and aided in weight loss. She was not fully aware of what she was taking, but she thought it might have been amphetamine since it came in a “large jar with many capsules.” Testing verified the presence of methamphetamine.

These results were shared with Ms Martin, to her genuine surprise, and she expressed earnest motivation to stop methamphetamine use. Unfortunately, over the next year, she eventually met criteria for stimulant (methamphetamine) use disorder. This paralleled toxic developments in her relationship. She described a continued strong sexual attachment to her partner, and she remained intimate with him despite knowledge that he was simultaneously sexually active with her mother. She later bashfully admitted engaging in group intercourse with her partner and mother. During intercourse she described her partner’s derogatory and sadistic tendencies, which she felt she “deserved.”

Eventually, she developed disgust toward him. This resulted in an internal conflict because while she described feeling revolted by him, she simultaneously experienced severe loneliness and feelings of abandonment when he did not give her attention. This fueled further methamphetamine use as she wanted to be “skinny and pretty.”

The ongoing sexual relationship between her partner and mother resulted in significant tension within the apartment they all shared. On multiple occasions, Ms Martin described anxiety that her partner and mother were colluding against her. Methamphetamine use may have intensified these feelings. Although at times she expressed a desire to leave, she felt she had nowhere to go. Her partner contributed to paying bills, which further complicated her situation.

A patient presents with multiple substance use disorders super-imposed on mood and anxiety disorders. Where does a clinician even begin?

Addiction & Substance Use

Afghanistan Veterans Struggling With Mental Health

To Treat or Not to Treat? The Conundrum of Likeability

Turning Over a New Leaf

The Case for Caution When Prescribing Benzodiazepines

Reducing Opioid-Involved Overdose Deaths: States’ Prevention and Response Efforts

Developing a Novel Psychedelic: Salvinorin A

I Had to Use

Cannabis Confusion

Anti-Fentanyl Vaccines as Medical Solutions to Overdose Deaths

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