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“The current opioid crisis has been responsible for the largest increase in deaths associate with opioids that we have ever known,” said Nora D. Volkow, MD, at the 2021 Virtual American Psychiatric Association Annual Meeting.

Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, discussed how the pandemic has exacerbated the opioid crisis in the session, “

Collision of the Opioid Crisis and the COVID-19 Pandemic.”

In March 2020 during the outset of the pandemic, the number of people reporting drug use rose significantly.

 The top 4 drugs were nonprescribed fentanyl, cocaine, heroin, and methamphetamine. Overdoses increased up to 42% per month during the pandemic.

 If an individual had SUD and were infected with SARS-CoV-2, the likelihood of dying increased, especially for black men.

As the amount of drug use increased, so did the problems. The pandemic presented a number of key challenges for individuals with substance use disorder (SUD), Volkow noted, including: stigma, isolation, and loss of work/homes. These challenges prevented individuals with SUD from getting proper care, or worsened their condition. Volkow gave an overview of these issues and their impacts.

“We know that people with opioid use disorder… are terribly stigmatized,” Volkow stated. “It’s very hard sometimes to convince people with an opioid use disorder to go to a hospital because they don’t like to be discriminated against or mistreated.”

Stigma and the belief they will not receive thoughtful care already kept some individuals with SUD from checking into a hospital; the pandemic worsened this likelihood. Both hospitals and prisons became hotbeds for the SARS-CoV-2 virus, places often with higher concentrations of individuals with SUD.

“In order to reverse an overdose, someone has to give them naloxone,” Volkow said. “But if you are isolated, and start shooting by yourself, the likelihood of getting naloxone is much less likely.”

According to Volkow, reports from the community suggest an increased number of overdose deaths in homes where the individual was alone.

“Economic challenges are some of the stress source that leads people to take more drugs to try to cope,” Volkow relayed.

Homelessness was also associated with an increased likelihood of contracting the SARS-CoV-2 virus, due to social distancing problems.

Volkow wants to increase research on topics like telemedicine and changes in the justice system, and how they can be furthered post-pandemic. Expanding access to treatment of comorbid conditions via telemedicine, and releasing nonviolent inmates with SUD, are just a few ideas she has.

Volkow posed the following question for the audience to ponder: “What is the structure we need to provide for these individuals to be successful in adjusting to their community and not be at risk for relapse?”

1. Millennium Health. Signals report COVID-19 special edition. July 8, 2020. 

https://www.millenniumhealth.com/news/signalsreportcovid/

2. Overdose Detection Mapping Application Program. 

3. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. 

According to Nora D. Volkow, MD, Director of the National Institute on Drug Abuse, drug use and overdose deaths have significantly increased since the outset of the pandemic. What made it worse?  

A Tale of Two Crises: Fighting the Overdose Problem During the Pandemic 

The US Food and Drug Administration (FDA) has approved a higher dose naloxone hydrochloride nasal spray product to treat opioid overdose. The freshly approved product delivers 8 mg of naloxone into the nasal cavity, whereas previously FDA-approved products were 2 mg and 4 mg naloxone nasal spray products. This approval reflects the FDA’s commitment to address the opioid crisis.

“Today’s action meets another critical need in combatting opioid overdose,” Patrizia Cavazzoni, MD, director of the FDA’s Center for Drug Evaluation and Research, said to the press. “Addressing the opioid crisis is a top priority for the FDA, and we will continue our efforts to increase access to naloxone and place this important medicine in the hands of those who need it most.”

Naloxone, created to help reduce opioid overdose deaths, can be administered by individuals with or without medical training. If is administered promptly, naloxone can counter the overdose effects quickly, even within minutes. The approval of the 8 mg naloxone nasal spray adds another tool in the arsenal of combatting opioid overdoses.

The FDA has recently taken several steps to make naloxone products more widely available, which include: encouraging approval of over-the-counter naloxone products; requiring opioid pain reliever manufacturers to add new recommendations about naloxone to prescribing information; and extending the shelf life of naloxone nasal spray from 24 months to 36 months.

1. US Food and Drug Administration. FDA approves higher dosage of naloxone nasal spray to treat opioid overdose. News release. April 30, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-approves-higher-dosage-naloxone-nasal-spray-treat-opioid-overdose?utm_medium=email&utm_source=govdelivery

The FDA approved a higher dose of naloxone to treat opioid overdose deaths. 

Addressing the Opioid Crisis: A New Approval 

What is addiction, and how can psychiatrists best respond to the opioid (and other drug) epidemic? What have we done wrong about it in the medication and other effective treatments for addiction? What does addiction do to the brain?

Lloyd I Sederer, MD, a psychiatrist, public health expert, and writer provides key insights on what we can do to save more lives from overdose deaths.

Dr Sederer is adjunct professor at the Columbia University School of Public Health; director of Columbia Psychiatry Media; Chief Medical Officer of 

. He has been chief medical officer of McLean Hospital; affiliated with Harvard; Mental Health Commissioner of New York City; and Chief Medical Officer of the New York State Office of Mental Health, the nation’s largest state mental health agency. The mission of 

 is to find the causes of and cures for mental illness.

Ink Stained for Life: Coming of Age in the 1950s. A Bronx Tale

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.



Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.

How can we save more lives and prevent overdose deaths? Lloyd I Sederer, MD, a psychiatrist, expert in public health, and author provides insights.

Lloyd Sederer, MD: A Conversation About Addiction and the Opioid Epidemic

Opioid addiction has deep, troubling roots in American history. Not merely 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 

, which has roots in 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, however. 

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 Black veterans, who lacked equitable access to opiates, a pattern that presaged the opioid underprescribing experienced by Black Americans in recent decades.1 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 longstanding racial inequalities in access to opioid medicines.

Historical Opioid Use Patterns in 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, frequently appeared in medical journals, monographs, textbooks, and even 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 the so-called opium habit were frequently victim-blamed, stigmatized, and even institutionalized.

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

 from physicians’ prescriptions or medical advice.

 Opiates were standard remedies for hundreds of ailments, including dysentery, cholera, malaria, pneumonia, menstrual pain, painful injuries and wounds, and more. Surveying 30 antebellum American medical textbooks, 

commentaries and formularies, medical handbooks, medical dictionaries, and home health guides published between 1813 and 1858, I identified approximately 150 distinct ailments for which opiates were indicated. The figure fluctuates slightly depending on how one classifies certain illnesses, as many nineteenth-century medical diagnoses do not map precisely on to modern diagnoses.

 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 

, opium was “the ‘Magnum Dei Donum’”—or, the great gift of God—“of the 

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 U.S. 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, prompting surgeons to rely more heavily than ever on opiates, including newly available hypodermic morphine injections.

 summed up the medical consensus of the day when it described opium as the most “indispensable drug on the battlefield—important to the surgeon, as gunpowder to the ordinance.”

Accordingly, military surgeons 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, there being 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 

 with cases of men whose lives were upended by addiction.

Black Civil War Soldiers and Opiate Addiction

Racial disparities were evident among Civil War veterans addicted to opiates, the majority of whom were disproportionately white. Although Black soldiers comprised approximately 10% of the U.S. 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, 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 “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.”9 The next year, a white Alabama physician also 

 that “the opium habit is rare” among the Black population after the Civil War.10This racial gap persisted for decades.

Surveying the records of morphine maintenance clinics that dotted the United States from 1910s to 1920, historian David Courtwright 

 that while the southern white population experienced the highest rate of opiate addiction in the nation, few Black southerners appeared 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 

 that Black Americans were too “simple-minded” to experience mental overstimulation, precluding them from insanity and opiate addiction.

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 whites often did.9 This constellation of racist beliefs was developed by antebellum white southerners to justify keeping Black people enslaved and to ward off abolitionist critiques.12 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 whites, 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.

Prescription records from the war are exceptionally rare, and none are extant for Black regiments. But anecdotal evidence suggests that army surgeons, who were overwhelmingly white, often refrained from prescribing opiates to wounded Black soldiers because they believed that Black men were not troubled by pain. One white surgeon assigned to a Black regiment refused to give painkillers to a soldier whose foot was partly severed by shrapnel. Under such circumstances the standard of care for white soldiers was morphine, given early and often. But when confronted, the surgeon claimed that the wounded man in question “was not suffering much pain,” despite the gruesome nature of the wound.

 The surgeon in this episode—and likely countless similar, unrecorded incidents—seems to have been motivated by the mainstream contemporary medical belief that Black men were impervious to painful injuries that would have debilitated white soldiers and warranted opiates.

Doctors also seem to have avoided giving opiates to Black soldiers debilitated by diarrhea, although surgeons usually administered opiates to white soldiers afflicted by the same illnesses. Surgeons knew that well-timed, liberal administration of opiates could, and often did, stave off soldiers’ deaths by dehydration, the risk of poisoning or addiction notwithstanding. Consequently, the mortality rate for diarrheal sicknesses among white troops—for whom surgeons prescribed opiates liberally—was a relatively low 17.3%. In contrast, the mortality among Black troops was 33.9%, nearly double that of white soldiers.

 This excessive mortality suggests that Black soldiers did not have access to prescription opiates, the standard of care for diarrheal ailments.

Black soldiers’ lack of access to opiate analgesics and antidiarrheals was typical, not exceptional, when considered within the broader scheme of Civil War medicine. Indeed, scholars have documented pervasive racism in Civil War military and humanitarian medicine, which diminished the quality of medical care accessible by Black Americans and resulted in thousands of avoidable Black deaths during the Civil War and its aftermath.

Persistent Racial Inequalities in the Opioid Crisis, Past and Present

A troubling undercurrent of racial inequality runs through the United States’ historical and ongoing opioid crises. Racial disparities in access to essential opioid medicines has been a persistent feature in American health care, both during the Civil War era and in recent decades. Amidst the ongoing opioid crisis, multiple studies have found that Black Americans are less likely to suffer from prescription opioid addiction than white Americans. This trend is because, like Black Civil War veterans in the late 19th century, African Americans today have less access to prescription opioid painkillers than white Americans. Persistent 

 in opioid prescribing rates have been so extreme that, until recently, white Americans were about 

 to die from prescription opioid overdose as African Americans.

The relative infrequency of opiate addiction among Black Americans when compared with white Americans has been touted as a “protection” shielding African Americans from the 

 of the opioid crisis.20 But considered in historical context, such rhetoric misses the mark. While it is true that during the Civil War-era opioid crisis and that of today, iatrogenic opioid addiction has been less prevalent among Black Americans than whites, this racial disparity should not be celebrated as a metaphorical silver lining. Instead, the relative infrequency of prescription opioid addiction among African Americans in the last century and a half merely reveals the longstanding, destructive influence of structural racism in American health care that has been, and continues to be, manifested in Black Americans’ unequal access to essential opioid medicines.

Special thanks to Greg Eghigian, PhD, History of Psychiatry Editor for 

is Postdoctoral Scholar, George and Ann Richards Civil War Era Center, Pennsylvania State University, State College, PA. His website is 

1. Jones JS. Opium Slavery: Veterans and Addiction in the American Civil War Era. PhD Dissertation, Binghamton University, 2020.

Preventing and Treating Narcotic Addiction—A Century of Federal Drug Control

The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885.

 Cambridge, MA: Harvard University Press; 1986.

Nineteenth century drug therapy: computer analysis of the 1854 prescription file of a Burlington pharmacy

5. Wilson TD. On the effects of opium upon the system. 1857, Waring Historical Library Inaugural Theses Collection, Waring Historical Library, Medical University of South Carolina, Charleston, South Carolina, 2. Accessed February 23, 2021. 

http://digital.library.musc.edu/cdm/compoundobject/collection/wit/id/2776/rec/10

Marrow of Tragedy: The Health Crisis of the American Civil War

. Baltimore, Maryland; Johns Hopkins University Press: 2013.

A Manual of Military Surgery. Prepared for the Use of the Confederate States Army.

 Richmond, Virginia: Ayres & Wade; 1863. Accessed February 23, 2021. 

https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-0257706-bk#page/4/mode/2up

Opium Slavery: Civil War Veterans and Opiate Addiction

9. Roberts JD. Opium Habit in the Negro. 

10. Tipton F. The Negro Problem from a Medical Standpoint. 

 1886:569-570. Accessed February 23, 2021. 

https://archive.org/details/101710951.nlm.nih.gov/page/n1/mode/2up

The Hidden Epidemic: Opiate Addiction and Cocaine Use in the South, 1860-1920

Aberration of Mind: Suicide and Suffering in the Civil War-Era South,

 Chapel Hill: University of North Carolina; 2018: 85-88.

Medical Bondage: Race, Gender, and the Origins of American Gynecology.

 Athens: The University of Georgia Press; 2017.

Washington, Eagles on Their Buttons: A Black Infantry Regiment in the Civil War.

 Columbia: University of Missouri Press; 1999:22-23.

Intensely Human: The Health of the Black Soldier in the American Civil War.

 Baltimore, Maryland: Johns Hopkins University Press; 2008:11.

 Sick from Freedom: African-American Illness and Suffering During the Civil War and Reconstruction.

 New York: Oxford University Press, 2012.

Trends in Black and White Opioid Mortality in the United States, 1979–2015

Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005-2016

 Baltimore, Maryland: Johns Hopkins University Press, 2014:194-195.

A ‘Rare Case Where Racial Biases’ Protected African-Americans

Black soldiers’ lack of access to opiate analgesics and antidiarrheals was typical, not exceptional, when considered within the broader scheme of Civil War medicine.




Race and Opioids: Lessons From the Civil War-Era Opioid Addiction Crisis

In the midst of a nationwide opioid epidemic, there is a population that is largely being ignored. According to a large cohort study, only a small percentage of teens receive proper aftercare following near-fatal overdoses. 

 examined data from more than 4 million Medicaid enrollees (N = 4,039,216) and found that only 1 in 54 youths aged 13 to 22 years received evidence-based pharmacotherapy after an overdose. Unfortunately, it appears that proper care in this patient population is given in very few cases (

 invited lead author Rachel H. Alinsky, MD, MPH, to share insights from the study. Alinsky is an adolescent medicine and addiction medicine fellow at 

Johns Hopkins University School of Medicine

: Your research highlights the need for quality treatment, especially for younger patients. What insights can you provide about interventions and obstacles to treatment?

We need to find effective interventions that can link adolescents and young adults directly into treatment after an opioid overdose. We also need to evaluate the barriers to accessing care at the time of overdose (such as insurance restrictions, lack of community providers or treatment centers, and stigma), and find strategies to mitigate these barriers. System-level changes are necessary, such as targeting federal funding for research and treatment for youth, decreasing insurance barriers, and increasing the availability of youth-serving physicians and addiction treatment centers.

 In the study, you and your colleagues noted, “Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment.” Is that because these youths have hit rock bottom?

In the addiction treatment field, we do not abide by that old adage—that people have to hit rock bottom before they are ready to get treatment. That is somewhat of a myth. What we are trying to emphasize in our article is that overdose is a particularly crucial time when we can draw someone into treatment because they are presenting into the medical setting, seeing doctors, and we have this opportunity to interact with them and offer them treatment. Coming into the emergency department with an overdose may be the only time this person is sitting face-to-face with a doctor, and we want to capitalize on this opportunity to offer the best care we can to the patient.

Of course, that does not mean they did not want treatment a month ago or a week ago—they very well might have wanted treatment but did not know how to access it in our very difficult-to-navigate addiction treatment system. So when the patient is physically with us after an overdose, we have the chance to help them gain access to lifesaving treatment.

PT: What are the key takeaway points from the study?

Prior to this study, we knew that teens and young adults were about one-tenth as likely as adults to receive treatment for opioid use disorder in general.

 And while we knew that more than 4000 adolescents and young adults between the ages of 15 and 24 die from an 

 very little was known about health care use following nonfatal opioid overdose in youth. We were interested in figuring out the extent to which adolescents and young adults are receiving evidence-based treatment after a nonfatal opioid overdose.

We found that fewer than 1 in 50 adolescents and young adults who had an opioid overdose received the standard-of-care medication treatment that is recommended by the American Academy of Pediatrics.

 We also found that youths with opioid overdose have a 

; more than 8% of youths with heroin overdose experience another overdose within 3 months.

When an adolescent or young adult goes to the hospital with an emergency, you expect them to get the treatment they need. But here we see that less than 2% are getting that treatment, which would not be acceptable for any other medical condition. In pediatrics, it would be unacceptable if only 1 in 50 youths with asthma [received] the standard treatment when they came into the emergency department, or if 1 in 50 youths with diabetes [received] the standard treatment when they were hospitalized with diabetic ketoacidosis. Pediatricians would not find that treatment gap acceptable. Yet this is where we are now with the treatment for youths who have an opioid overdose—and we need to do better for them.

Additionally, with such high rates of recurrent overdose, it is even more important to get these youths into effective treatment as soon as possible, so we can try to prevent another overdose.

Finally, prescribing practices should be closely monitored in young people; they are a critically neglected patient population when it comes to addiction monitoring. As verified in an earlier study of 2,752,612 adolescents: “Safe opioid prescribing practices are critical to mitigate the risk of prescription opioid overdose in adolescents and young adults.”

PT: What are the key issues in recognizing opioid use disorder in youth?

The diagnosis of opioid use disorder is straightforward and is based on how many criteria an individual meets from a set of 11 criteria defined in DSM-5. In the case of youths who are presenting with opioid overdose, there is a chance that clinicians may view this as a standalone incident, and not recognize it as a manifestation of an adolescent’s underlying opioid use disorder. Thus, clinicians should be thinking about, and evaluating for, opioid use disorder in any youths that present with an overdose. Clinicians should probe for issues such as taking the opioid in larger amounts than intended, unsuccessful efforts to cut down use, cravings, recurrent use despite failure to fulfill obligations at school or home, or recurrent use in physically hazardous situations.

In terms of treatment, psychiatrists and other providers should offer medication for opioid use disorder as first-line treatment, consistent with recommendations from the 

. These medications include buprenorphine, methadone, and naltrexone. Pharmacological interventions can be combined with behavioral health services such as therapy or counseling. The provider will need to determine the level of care that will best support the patient in their current stage of treatment—inpatient hospitalization, residential treatment, intensive outpatient, or outpatient treatment.

We know that medication is effective and lifesaving for opioid use disorder; large studies in adults have found that medication cuts the risk of death in half.6,7 We also know that youths who are on medication stay in treatment longer.8 Because so few youths actually ever receive this effective addiction treatment, an overdose can be an ideal opportunity to link someone into care who has not been able to access it previously.

How can clinicians advise their patients and families on finding the most appropriate care?

Patients and their parents can advocate for treatment by asking their doctors about treatment when they are in the emergency department with an overdose. Some emergency departments have programs where patients can immediately start on medication treatment; the programs can then link them to a provider in the community. These programs have been shown to be extremely effective, with much higher rates of individuals entering and staying in treatment than if someone is simply handed a phone number to call to set up treatment.9 If that sort of linkage is not available, families should ask to be referred so their teen or young adult can receive treatment in their community as soon as possible.

Clinicians or patients and families who want to find available treatment resources within their community can use the treatment locator provided by the Substance Abuse and Mental Health Services Administration (

). Here you can enter your zip code and find all the available addiction treatment centers, sorting by services offered. It is also possible to specifically look for buprenorphine prescribers or methadone programs from that web page.

1. Alinsky RH, Zima BT, Rodean J, et al. 

Receipt of addiction treatment after opioid overdose among Medicaid-enrolled adolescents and young adults

2. Chua KP, Brummett CM, Conti RM, Bohnert A. 

Association of opioid prescribing patterns with prescription opioid overdose in adolescents and young adults

3. Overdose death rates. National Institute on Drug Abuse. Updated March 10, 2020. Accessed November 30, 2020, 2020. 

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

4. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. 

5. Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder.

6. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. 

7. Medications for Opioid Use Disorder Save Lives. The National Academies Press. Accessed November 30, 2020. 

http://www.nationalacademies.org/hmd/Reports/2019/medications-for-opioid-use-disorder-save-lives.aspx

8. Hadland SE, Bagley SM, Rodean J, et al. Receipt of timely addiction treatment and association of early medication treatment with retention in care among youths with opioid use disorder. 

9. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. 

With opioid use disorder, a tiny fraction of young patients are getting treatment, which would not be acceptable for any other medical condition. 

Improving Care in Teens With Opioid Use Disorder

 and Senior Vice President at Appriss Health. She is a physician and healthcare services researcher, trained in Critical Care and Emergency Medicine, and faculty at Johns Hopkins University School of Medicine.

The reported increase in opioid related overdoses, likely fed by the disturbances of COVID-19, necessitates a need for more widely-accessible Naloxone, an emergency life-saving treatment. 

Naloxone and Combatting the Rising Opioid Fatalities 

Although these medication-assisted treatments have been approved by the FDA and have strong empiric evidence for superior outcomes, it is important to know the good and the bad.

Pros and Cons of Medication-Assisted Treatment for Opioid Use Disorder

A. A 78-year-old in hospice care for terminal lung cancer

B. A 68-year-old w history of depression, anxiety, chronic pain, +drug screen for cocaine/opioids/prescribed benzodiazapines

C. A 65-year-old with hepatocellular carcinoma, recently enrolled in palliative care, w a comorbid, severe alcohol-use disorder

D. A 90-year-old who has chronic back pain, neurocognitive disorder and history of falls

E. A 64-year-old status/post hip replacement surgery in PACU

The short vignettes in this quiz highlight the importance of understanding the delicate balance between risks and benefits when prescribing opioids.

Mini Quiz: Prescribing Opioids to the Elderly

is Resident Physician, Department of Psychiatry and Behavioral Sciences, Nassau University Medical Center, East Meadow, NY;

is Addiction Psychiatry Fellow, Dartmouth-Hitchcock Medical Center, Lebanon, NH; and 

is Clinical Associate Professor, Department of Psychiatry and Behavioral Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, and Medical Director, Consultation-Liaison Psychiatry, Cape Cod Healthcare, Hyannis, MA.

Opioid-related overdoses are now the leading cause of death in Americans aged younger than 50 years, with a resultant 2.5 months of life expectancy lost.

 While this includes deaths from pain pills and illicit heroin, the overwhelming initial source of addiction is prescribed opioids; 83% of heroin users started off abusing prescription opioids. More than 6 out of 10 deaths involve prescribed opioids.

 in the number of prescriptions written as well as dosages per prescription.

 yearly to supply every American with an average of 36 pills. In addition, in 2016, overprescribing of postsurgical opioids resulted in 3.3 billion unused pills flooding into communities, making these available for diversion and misuse.

Use of naloxone, an opioid receptor antagonist, has been shown to reverse opioid-induced respiratory suppression. Current evidence suggests that bystanders can and will use naloxone to reverse opioid overdoses when appropriately trained. This training is possible through community-based opioid overdose prevention programs. There is a movement to increase public awareness and training on the use of naloxone, with laws being passed that require students as young as elementary school age to receive training.

Despite this, there has been only a modest increase in naloxone prescribing between 2009 and 2015, from 2.8 million to 3.2 million.

 The relatively slow adoption of naloxone is in part due to stigmatization and absence of familiarity with the treatment among clinicians and opioid users. Most physicians do not receive formal training on the use of naloxone and its various methods of delivery. There is a need to increase prescribing and to improve clinicians’ training to effectively help ameliorate overdose response and deaths (

Because of the effects of the overdose epidemic, states passed legislation designed to enhance layman access to naloxone and give legal immunity to medical professionals who prescribe or dispense naloxone as well as to those who administer naloxone. Individuals such as emergency medical services personnel, police officers, and firefighters as well as those authorized to administer naloxone are required to undergo training and education in recognition of signs and symptoms of overdose, techniques for administration of naloxone, and referral to emergency medical services. Residents and fellows are the exception. They undergo training in clinical skills such as advanced cardiac life support, pediatric advanced life support, and basic life support; however, they do not receive naloxone and opioid reversal training. Training is relatively simple in part because of the absence of complicated administration requirements or serious adverse reactions (

Naloxone competitively antagonizes the delta (Î´), mu (Î¼), and kappa(Îº) receptors with a 10-fold higher affinity for Î¼ than Îº. Given its ability to displace receptor-bound opioid molecules, its main use is intended for reversal of opioid-induced respiratory 

 Evidence of efficacy is noted within 30 seconds of intravenous administration; however, the most common route is nasally with a spray. This allows for convenient administration to patients by their relatives at home. The recommendation is to create an “overdose plan” to share with friends, partners, and/or caregivers. Such a plan contains information on the signs of overdose and how to administer naloxone or otherwise provide emergency care.

A medical provider must have a high suspicion and low threshold for use of naloxone, since overdose patients are usually found unresponsive or sedated. This is particularly true in cases where getting a collaborative history from a relative or close companion is difficult.

Currently, there are 4 naloxone delivery systems (

The onset of action of naltrexone and the duration depend on the route of administration. When used intravenously, it has the quickest onset of action (1-2 min) compared with subcutaneously (5 min), intramuscular (6 min), and nebulized (5 min).

 recommend initial doses of 0.4 to 2 mg via intramuscular or intravenous routes, followed by repeated doses up to 10 mg.

 Dosing is empirically determined; however, many factors need to be considered including morphine equivalence in the system, naloxone administration route, concurrent medications in the system such as benzodiazepines, and overall opioid tolerance.

Typical administration begins with a low dose to avoid precipitating withdrawal. Considerably higher doses of naloxone are required for potent opioids such as fentanyl.

 This should be a consideration in an individual who does not respond to the initial dose. Because of the increased prevalence of fentanyl and other powerful synthetic opioids, the naloxone requirements are on the rise. Given the potency of fentanyl, even multiple doses are sometimes unsuccessful.

Naloxone’s safety profile is extremely high especially when used in low doses and titrated to effect. When administered to nonopioid-dependent and nonopioid-intoxicated healthy volunteers, it produces no clinical effects even at high doses. Even in tolerant patients, rapid opioid withdrawal-although unpleasant-is not always life-threatening.

The duration of action of some opioids exceeds that of naloxone and can result in recurrence of CNS and respiratory system depression. It is important to be prepared for additional administrations and to be able to facilitate ICU admission for monitoring after reversal. It is also pertinent to consider the limitation of naloxone when dealing with mixed agonists/antagonists and partial agonists because of the low efficacy of the drug.

When used in cases of opioid overdoses, the abrupt reversal can sometimes result in vomiting, sweating, increased blood pressure, tremulousness, and tachycardia. Naloxone can also cause acute withdrawal symptoms in opioid-dependent individuals. Agitation, yawning, diaphoresis, rhinorrhea, lacrimation, nausea, vomiting, and diarrhea are not life-threatening.

 At the same time, in rare cases, it is possible to encounter 

 such as pulmonary edema, acute respiratory distress syndrome, seizures, and cardiac arrhythmias.

More than 6 out of 10 deaths involve prescribed opioids. The authors address guidelines for who should (and who should not) receive a naloxone prescription.

Opioid Related Disorders