Hero

Videos

Slideshows

Articles

Podcasts

Poll

 death of 54-year-old actor, Michael K. Williams, confirmed to be due to an overdose of heroin, cocaine, and fentanyl,

 was a sobering reminder that the opioid crisis is far from a problem limited to white Americans, although it has 

 about his own struggles with substance abuse, and celebrities disclosing mental illness can be a powerful method to increase help-seeking behaviors, especially for minoritized communities.

 In addition, he was quite invested in community work for children, founding 

, a charitable organization that creates community centers to provide children with safe places to play and to learn. Williams himself experienced significant childhood trauma and admitted that he began to use substances as an adolescent to 

 In fact, studies have shown that most adults who struggle with substance use disorders (SUDs) begin using substances 

 If psychiatrists want to combat the opioid epidemic, they must appreciate the needs of often-overlooked communities and start early—in childhood and adolescence.

I recently attended a lecture about the effects of maternal opioid use on newborns. The presenter showed slides depicting mothers with opioid use disorders (OUDs) through a humanizing, rather than criminalizing, lens. All these mothers happened to be white. This was a particularly troubling coincidence, given the racialization of drug use and the racist pattern in the media—the favorable portrayal of rural and suburban white opioid users versus the unfavorable portrayal of black opioid users living in urban communities.

 Black Americans with OUDs are too often represented as poor, urban, criminals injecting opioids. This is a racially inaccurate depiction in and of itself, given that Black individuals with OUDs also live in the suburbs and in rural areas.

In 2017, the US Department of Health and Human Services declared the opioid epidemic a 

 after witnessing the monumental number of deaths due to opioid overdose.

 Since then and through 2019, although white deaths have been on the decline, opioid overdose deaths in Black Americans, and in particular in Black men, have been 

 Synthetic opioids have hit Black communities disproportionately hard. From 2011 to 2016, Black Americans had the greatest increase in opioid-related death rates due to synthetic opioids, such as 

 and from 2016 to 2017, Black Americans experienced a 61% increase in synthetic opioid fatal overdoses, compared to a 

The current interventions used for OUDs, and arguably SUDs overall, are not working optimally for everyone. To be sure, white individuals have been harmed by the opioid crisis, and before the onset of fentanyl they had the highest rates and numbers of deaths due to opioid overdose.

 However, the opioid crisis is not only harming white people, and Black people are often left out when it comes to OUD interventions.

OUD treatment interventions should not be the same for all populations, because all populations are not treated equally when it comes to OUDs. The racist war on drugs, which disproportionately targeted 

 is only one example. Black individuals are disproportionately criminalized for SUDs, making it more difficult for them to trust and therefore access substance use treatment. Even though white individuals are more likely to sell drugs than Black individuals, Black individuals are 

 Black Americans are also more likely to be arrested for drug possession, even though white and Black individuals use substances at similar rates.

Racial disparities exist even in the distribution of psychopharmacological treatment for OUDs.

 There is differential access to buprenorphine and methadone, with the former less likely to be available in Black communities versus the latter. Methadone requires daily appointments, while buprenorphine is a take-home-pill. In essence, the more convenient treatment is less accessible for Black people. OUD interventions must do more to target Black communities specifically, and advertisements and slides for OUD interventions that feature white-only families misrepresent the true demographics of the epidemic. Black patients must be reassured that their SUDs will be humanized and treated as psychiatric disorders, not as punishable crimes.

During the opioid crisis, there has been less attention on the impact of OUD on children and adolescents. Although a myriad of research studies exist on OUDs’ impact on newborns, children 1 year or older get less attention when it comes to OUD research, with only 2% of federal funding for addiction research focusing on children or families.

 Beyond research, there is a need for clinical training on navigating OUDs in children and adolescents—and additionally, helping to prevent them. Children and adolescents of parents with OUDs should receive anticipatory guidance about opioid use, including support in understanding why they may be at greater risk for developing an OUD.

To be sure, child and adolescent psychiatrists have these sorts of conversations with their patients individually all the time, but having these conversations (or not) is often left up to the psychiatrist’s discretion, rather than having it be a standard of care. As an adult/child psychiatry resident, I have received the bulk of my training in SUDs from my time with adults, rather than with children.

While we are certainly trained to ask about SUDs in children and to monitor and treat them once they occur, what about preventing them? Perhaps newborns who suffer from neonatal abstinence syndrome should be flagged to receive preventative SUD care when they reach a certain age, although the long-term psychiatric outcomes of newborns exposed to opioids in utero is still a subject very much debated.

 Perhaps children who are exposed to trauma should be counseled about the risk of engaging in substance use, among risky behaviors, in an attempt to cope, especially if these children are already being seen by a child and adolescent psychiatrist for other reasons. One thing is for sure, the opioid crisis is far from a white people problem or an adult problem, for that matter. And, sadly, it is far from over.

 is an adult/child psychiatry resident at Yale Child Study Center/Yale School of Medicine. She is also a Public Voices Fellow of the OpEd Project at Yale University.

1. Gold M, Bromwich JE. Michael K. Williams died of a drug overdose, authorities say. 

. September 27, 2021. Accessed September 26, 2021. 

2. Shihipar A. The opioid crisis isn’t white. 

. February 26, 2019. Accessed September 26, 2021. 

3. Calhoun AJ, Gold JA. “I feel like I know them”: the positive effect of celebrity self-disclosure of mental illness. 

4. Murray E. Michael K. Williams never hid his addiction struggles. Addiction Center. September 9, 2021. Accessed September 30, 2021. 

5. Jackson D. Everything Michael K. Williams has said about addiction and his mental health struggles. 

. September 24, 2021. Accessed September 26, 2021. 

6. National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: a research-based guide. Revised January 2014. Accessed September 30, 2021.

7. Netherland J, Hansen HB. The war on drugs that wasn’t: wasted whiteness, “dirty doctors,” and race in media coverage of prescription opioid misuse. 

8. US Department of Health and Human Services. HHS acting secretary declares public health emergency to address national opioid crisis. October 26, 2017. Accessed September 26, 2021. 

9. White C. Progress against the opioid epidemic is not reaching Black Americans. 

. February 8, 2021. Accessed September 26, 2021. 

10. Agency for Healthcare Research and Quality. Blacks experiencing fast-rising rates of overdose deaths involving synthetic opioids other than methadone. February 2020. Accessed September 26, 2021.

11. Goodnough A. In cities where it once reigned, heroin is disappearing. 

. May 18, 2019. Accessed September 26, 2021. 

12. United States Sentencing Commission. 2015 report to the Congress: impact of the fair sentencing act of 2010. 2015. Accessed September 26, 2021.

13. Ingraham C. White people are more likely to deal drugs, but black people are more likely to get arrested for it. 

. September 30, 2014. Accessed September 30, 2021. 

14. Winstanley EL, Stover AN. The impact of the opioid epidemic on children and adolescents. 

15. Larson JJ, Graham DL, Singer LT, et al. Cognitive and behavioral impact on children exposed to opioids during pregnancy. 

How can psychiatrists improve substance use treatment for Black and pediatric patients?

The Opioid Crisis Is Neither a White Nor an Adult Problem

 from the American Medical Association (AMA), opioid prescriptions have gone down 44.4% nationwide in the past decade, and 6.9% from 2019 to 2020. Yet the country is experiencing a worsening overdose epidemic.

In order to address the epidemic, the AMA is urging policymakers to remove barriers to evidence-based care, and thus reduce mortality and improve patient outcomes.

“The nation’s drug overdose and death epidemic has never just been about prescription opioids,” said AMA President Gerald E. Harmon, MD. “Physicians, have become more cautious about prescribing opioids, are trained to treat opioid use disorder and support evidence-based harm reduction strategies. We use PDMPs [prescription drug monitoring programs] as a tool, but they are not a panacea. Patients need policymakers, health insurance plans, national pharmacy chains and other stakeholders to change their focus and help us remove barriers to evidence-based care.”

The report shows that, despite increased use of PDMPs, overdose and deaths are spiking. According to the report, physicians and other mental health professionals used state PDMPs more than 910 million times in 2020, and about 750 million times in 2019.

“With record-breaking numbers of overdose deaths across the country, these are actions policymakers and other stakeholders must take,” Harmon said. “The medical community will continue to play its part, and overall, the focus of our national efforts must shift. Until further action is taken, we are doing a great injustice to our patients with pain, those with a mental illness and those with a substance use disorder.”

Here are the AMA’s 7 recommendations for policymakers:

1. Remove barriers to evidence-based care for patients with a substance use disorder (SUD), including removing prior authorization and step therapy for medications to treat opioid use disorder, continuing federal flexibilities for take-home medication for opioid treatment programs, and continuing telehealth options for patients.

2. Remove barriers to opioid medications and treatment for SUDs in jails and prisons. There is no legal, medical, or policy reason to deny access to mental health care for incarcerated individuals.

3. Protect families by increasing access to evidence-based care rather than using the threat of family separation for persons who are pregnant, peripartum, postpartum, and parenting.

4. Support patients with pain by rescinding arbitrary laws and policies focused on restricting access to multidisciplinary, multimodal pain care. This might mean requiring health insurance companies and other payers to make nonopioid pain care alternatives more accessible and affordable.

5. State insurance commissioners, attorneys general, and the US Department of Labor must increase efforts to review health insurers’ policies on a regular basis to ensure they comply with the Mental Health Parity and Addiction Equity Act—and hold them accountable if not.

6. Support increased efforts to expand sterile needle and syringe exchange services programs, decriminalize drug checking supplies, and urge manufacturers to make naloxone available over the counter.

7. Develop and implement systems to collect timely, adequate, and standardized data to identify at-risk populations, fully understand polysubstance drug use, and implement public health interventions that directly address removing structural and racial inequities.

“Policymakers and other stakeholders have a choice of whether to pursue evidence-based strategies to support patients’ access to lifesaving and life- affirming care. Every effort must be made to remove health inequities and other barriers for patients with substance use disorders, mental illness and patients with pain. More of our loved ones will suffer and die if these barriers remain,” said Bobby Mukkamala, MD, Chair of the AMA Substance Use and Pain Care Task Force.

To read more on states’ efforts to combat the opioid crisis, see 

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

1. American Medical Association. 2021 Overdose Epidemic Report. September 21, 2021. 

https://end-overdose-epidemic.org/wp-content/uploads/2021/09/AMA-2021-Overdose-Epidemic-Report_92021.pdf

2. American Medical Association. Report shows decreases in opioid prescribing, increase in overdoses. News release. September 21, 2021. 

https://www.ama-assn.org/press-center/press-releases/report-shows-decreases-opioid-prescribing-increase-overdoses

The American Medical Association is urging policymakers to act now to prevent further opioid overdose deaths. 

The AMA’s 7 Recommendations for Reducing the Opioid Crisis

A clinical trial studying a vaccine for opioid use disorder developed by University of Minnesota Medical School researchers has enrolled its first participants. The phase 1 randomized placebo-controlled trial, funded by a grant from the National Institutes of Health, will test the safety and potential efficacy of a vaccine that could prevent both the euphoric and toxic effects of oxycodone.

“This medication approach is unique in that it can be used alone or in combination with other treatment medications and, importantly, may offer patients long-lasting protection against overdose if they relapse to opioid use. The long-term goal of this program is to develop a series of opioid vaccines that target other commonly used opioids, such as heroin and fentanyl. We are very excited about this research and hope to eventually provide a safe, new treatment option for patients with opioid use disorder,” said principal investigator Sandra Comer, PhD, director of the Opioid Laboratory in the Department of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons.

Comer will oversee a medical team led by Jeanne Manubay, MD, the study's medical director. Manubay will monitor the patients’ response to the vaccine, including their subsequent drug use and behaviors.

Trial participants are being enrolled at Columbia University in New York City and Clinilabs Drug Development Corporation, in Eatontown, New Jersey. Participants must be between the ages of 18 and 59, must be currently using opioids and not seeking treatment for drug use, and must have prior experience with intranasal opioid use.

Marco Pravetoni, PhD’s laboratory led the development of the series of vaccines and monoclonal antibodies that counteract depressed breathing and depressed heart rate induced by oxycodone, fentanyl, and heroin in preclinical studies.

The vaccine under observation stimulates the body’s immune system to produce antibodies to oxycodone. When a vaccinated individual takes oxycodone, the antibodies bind to the drug molecule and stop it from entering the brain, ultimately preventing the high the drug produces. As the vaccine selectively targets oxycodone, it will not interfere with US Food and Drug Administration approved medications, like methadone, buprenorphine, naltrexone, or naloxone.

“In this study, my laboratory will conduct pharmacokinetic and immunological monitoring in blood samples from immunized volunteers to ensure that they are making antibodies to oxycodone and determine whether or not the antibodies are preventing the drug from reaching the brain,” said Pravetoni.

The study plans to enroll up to 45 participants, who will be closely monitored for several weeks in inpatient units at Columbia University Irving Medical Center and at Clinilabs. Researchers will look for adverse events, determine participants’ response to oxycodone after vaccination, and then study their drug behavior on an outpatient basis.

“Clinilabs is privileged to be working with the University of Minnesota Medical School and Columbia University on this groundbreaking trial. Exploring a preventative vaccine to treat opioid use disorder has the potential to be life-altering for patients and their families who are battling opioid abuse,” said Gary Zammit, Clinilabs’ President and CEO.

Anti-Fentanyl Vaccines as Medical Solutions to Overdose Deaths

1. First-in-human clinical trial for a vaccine to treat opioid use disorders enrolls first patients. 

. September 7, 2021. Accessed September 14, 2021. 

https://www.worldpharmanews.com/index.php?option=com_content&view=article&id=5792:first-in-human-clinical-trial-for-a-vaccine-to-treat-opioid-use-disorders-enrolls-first-patients&catid=13:research

A vaccine that prevents oxycodone from entering the brain? This might be the safe, long-lasting, cost-effective solution for opioid use disorders.

A Vaccine to Treat Opioid Disorders: First Participant Enrolled in Trial 

Fentanyl and fentanyl analogues, such as carfentanil, are driving an opioid overdose crisis in North America.

 In 2019 alone, there were 3831 opioid-related deaths in Canada

 and 47,600 fatalities involving opioids in the United States (

 The COVID-19 pandemic has only heightened the tragic impact of opioids on individuals who use the drugs, on their families, and on communities across both countries.

 are needed for this complex problem, and efforts are already underway. To mitigate the overdose crisis, both Canada and the United States have implemented multiple public health and treatment strategies. Extant strategies include providing opioid agonist therapies (OAT), naloxone for reversing fatal opioid overdoses, and access to harm-reduction services. In addition, injectable/implantable buprenorphine is available in both countries. However, the opioid receptor 

, while available in the oral formulation in both Canada and the United States, is not available in the depot formulation in Canada. Currently, OAT with methadone or buprenorphine/naloxone are the first-line interventions for individuals with moderate-to-severe opioid use disorder (OUD).

 is preferred over methadone for its superior safety profile, these treatments have many limitations. Moreover, in Canada, there are barriers to accessing OAT, including reduced access to OAT prescribers in rural areas and a shortage of pharmacies that offer on-site OAT.

OAT clinics often lack psychosocial supports and, frequently, high out-of-pocket expenses prove problematic for individuals with OUD who have limited financial means.

 Similar economic, geographic, attitudinal, and organizational barriers exist in the United States.

 Additionally, in the United States, where public insurance providers favor methadone whereas private insurance providers favor buprenorphine/naloxone, health insurance barriers have caused rampant racial and economic disparities in OAT access across the country.

, Canada has taken several novel harm-reduction approaches to combat it. Harm reduction refers to a wide array of public health policies intended to reduce the adverse consequences of human behaviors, including, but not limited to, substance use. In the context of the opioid crisis, harm-reduction interventions have included rapid-access addiction medicine services, provision of take-home naloxone kits, supervised consumption facilities (SCFs), and education around overdose risk mitigation.

Historically, the success of harm-reduction services for OUD has been difficult to quantify; most studies have small sample sizes and poorly defined outcome measures. These studies have limited generalizability to most individuals with OUD, who respond to first-line treatments. However, mounting evidence demonstrates proof of efficacy and effectiveness for a range of harm-reduction services. Recent studies have shown that they can reduce opioid overdose mortality, infection-related complications, and crime commitment among individuals with treatment-refractory OUD (TR-OUD).

In recent years, Canadian health care providers have implemented 3 critical harm-reduction measures that have curtailed opioid-related fatalities: (1) heroin-assisted treatment (HAT), (2) hydromorphone-assisted therapy, and (3) SCFs. 

 provides a summary of each of these novel treatments.

We advocate for the provision of substantiated harm-reduction services in the United States that, following the Canadian example, could save countless lives by increasing access to evidence-based treatment options for OUD.

HAT, or heroin maintenance, is an evidence-based intervention for managing the symptoms of TR-OUD. Although definitions of TR-OUD vary, most studies refer to the failure to respond meaningfully to 1 or more first-line treatments for OUD (eg, methadone or buprenorphine/suboxone). HAT is available in Canada (eg, Vancouver and Montreal) and some European countries (eg, Germany, Switzerland, and the United Kingdom) and has shown efficacy in select groups experiencing TR-OUD. To receive HAT, individuals with TR-OUD visit a designated HAT clinic, where they receive injectable medical-grade heroin (diacetylmorphine) up to 3 times daily under strict nursing and medical supervision.

 In essence, most HAT clinics operate under a supervised consumption model.

Results from randomized controlled trials have shown promising findings for individuals with TR-OUD. In one trial, HAT reduced illicit heroin use, improved treatment retention, reduced criminal activities, and improved mental and physical health compared with methadone therapy.

 While HAT is more expensive than oral methadone treatment, the social and economic benefits justify its provision for select patients with TR-OUD who have not benefited from first-line therapies. Nonetheless, studies have shown an association between HAT and a higher risk of adverse events such as seizures and opioid overdoses

. Although HAT carries a more dangerous safety profile than other forms of OAT, HAT administration typically occurs in supervised clinical settings, which lessens these risks. Thus, while HAT carries an increased absolute risk of adverse events—including opioid overdose—it is still a harm-reduction measure as it lessens the risk relative to the unsupervised consumption of street-sourced heroin or fentanyl.

Given the regulatory restrictions in providing HAT, investigators in Vancouver, British Columbia, considered alternative strategies for treating individuals with TR-OUD. The search for alternative OAT led to hydromorphone, a synthetic opioid used to treat chronic pain. Consequently, researchers at St Paul’s Hospital in Vancouver conducted the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) trial.

In brief, the SALOME trial was an innovative study investigating the use of injectable hydromorphone (IH) as an alternative to intravenous diacetylmorphine (eg, HAT) for TR-OUD. The researchers aimed to establish the noninferiority of IH to HAT. Ultimately, the researchers found that delivering the 2 interventions under the same conditions (eg, supervised consumption facilities) led to positive outcomes in both groups. For example, participants receiving either treatment showed improved treatment retention, greater global functioning, reduced illicit opioid use, and diminished illegal activities.

 The SALOME trial was among the first to establish the efficacy of these harm-reduction measures for individuals with TR-OUD. Consequently, the SALOME trial results suggest that when diacetylmorphine is unavailable or other treatments are unsuccessful, IH can be a suitable alternative for treating severe TR-OUD.

In January 2019, Vancouver started the first hydromorphone tablet distribution program, based on the SALOME trial’s promising results. A qualitative study evaluated the program’s effects suggested that it can decrease illicit drug use, 

, and engagement in illegal activities, and can help address social inequalities surrounding drug use.

 Currently, in response to the COVID-19 pandemic and rising overdoses, take-home hydromorphone has been permitted, and the effects of this expansion can be promising for the widescale implementation of similar programs in rural, suburban, and urban settings.

 However, further study of injectable and oral hydromorphone in patients with TR-OUD in diverse settings is warranted.

 (SCFs) are safe, clean, indoor facilities where individuals can use preobtained drugs under the supervision of trained medical professionals to ensure safe injection or consumption by other methods (eg, oral or smoked). SCFs can implement rapid responses in cases of opioid overdoses, such as by providing intranasal or intramuscular naloxone.

 In recent years, mobile or pop-up SCFs have emerged in Toronto, Ottawa, Halifax, and other Canadian cities; these have been grassroots initiatives to address the unmet needs of special populations with TR-OUD or other substance use disorders. SCF initiatives can also offer assistance by providing counseling and psychosocial supports, referrals to social services, and access to medical and psychiatric treatment as necessary.

SCFs were first developed in response to the HIV epidemic in Vancouver when Insite—North America’s first SCF—proved to be a tremendous asset in combating the opioid crisis.

 SCFs also provides a multifaceted opportunity to address comorbidities, such as psychiatric illness, HIV/AIDS, and other infectious diseases. Because individuals with TR-OUD frequently experience co-occurring medical and psychiatric disorders, SCFs have created critical opportunities to engage with a population that can be otherwise difficult to reach. Studies have demonstrated the myriad benefits of SCFs, such as decreasing rates of overdose deaths, crime, and infectious disease transmission, while remaining cost-effective.

A recent study estimated the cost and impact of establishing SCFs in New York City. The results showed that an SCF could prevent 19 to 37 opioid overdose fatalities per year in that city, and save its health care system between $831,700 and $2.9 million as well.

 However, the establishment of SCFs remains controversial in the United States, and advocacy for drug policy changes must continue.

 has negatively affected all Canadian provinces and territories, with British Columbia, Ontario, and Alberta recording the highest number of opioid-related overdose deaths in 2019.

 The United States has also seen a widespread increase in the number of opioid-related deaths since the 2000s, with the northeastern, mid-Atlantic, and midwestern states being most affected.

 Currently, most of the overdose fatalities involve synthetic opioids such as fentanyl and its analogues,

 and most overdoses (more than 90%) appear to be accidental. The high prevalence of fentanyl as an adulterant in the illegal supplies of heroin and other injectable drugs (eg, cocaine and crystal methamphetamine) are the major factors accounting for the growing number of overdose-related deaths.

The rising number of opioid-related fatalities is a call to action to implement sustainable measures to prevent overdose occurrences beyond acute naloxone administration. Canada has implemented multiple harm-reduction measures since the beginning of its opioid crisis, which have reduced overdose mortality. For example, the current safe-supply programs focus on prescribing pharmaceutical-grade opioids, such as injectable hydromorphone and diacetylmorphine, to individuals who are at high risk of opioid overdose. This strategy is powerful in reducing the harms caused by fentanyl-related opioids on the illicit drug market, and as a result, overdose events have been prevented and overdose mortality has been decreased.

 Canadian and international studies on SCF have shown that the facilities are effective in reducing overdose fatalities, needle sharing, unsafe injection practices, and involvement in criminal activities.

As Canada and the United States seek comprehensive, collaborative, and evidence-based approaches to combat the current opioid crisis, they each can learn from the collective expertise and strategies implemented on the other side of the border.

is a third-year medical student at Touro College of Osteopathic Medicine in New York. 

is a fellow in addiction psychiatry at the University of Calgary’s Cumming School of Medicine.

is a staff psychiatrist in the addictions division at the Centre for Addiction and Mental Health (CAMH) and a lecturer in psychiatry, Temerty Faculty of Medicine, University of Toronto.

is an advanced practice clinical leader at CAMH, and a PhD candidate in the Bloomberg School of Nursing at the University of Toronto.

is professor of anthropology and psychiatry, and research chair in the social medicine theme, at UCLA’s David Geffen School of Medicine, Los Angeles.

is professor of psychiatry in the Temerty Faculty of Medicine at the University of Toronto and a clinician-scientist in the addictions division of CAMH in Toronto. He also serves as deputy editor of the journal Neuropsychopharmacology.

Acknowledgments - The constructive and critical comments of Eric C. Strain, MD, of John Hopkins University on the manuscript are gratefully acknowledged.

1. Ivsins A, Boyd J, Beletsky L, McNeil R. 

Tackling the overdose crisis: the role of safe supply.

2. Opioid- and stimulant-related harms in Canada [maps]. Government of Canada. June 2021. Accessed July 22, 2021. 

https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/maps

3. Overdose death rates. National Institute on Drug Abuse. Updated January 29, 2021. July 22, 2021. 

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

4. Opioid- and stimulant-related harms in Canada [key findings]. Government of Canada. Updated June 2021. Accessed July 22, 2021. 

https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants

5. Overdose deaths accelerating during COVID-19. News release. CDC; December 17, 2020. Accessed July 22, 2021. 

https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html

7. Priest KC, Gorfinkel L, Klimas J, et al. 

Comparing Canadian and the United States opioid agonist therapy policies.

8. Hansen HB, Siegel CE, Case BG, et al. 

Variation in buprenorphine and methadone treatment by racial, ethnic, and income characteristics of residential social areas in New York City.

Expanding supervised injection facilities across Canada: lessons from the Vancouver experience.

10. Heroin-assisted treatment (HAT). Drug Policy Alliance. February 2016. Accessed July 22, 2021. 

https://drugpolicy.org/sites/default/files/DPA%20Fact%20Sheet_Heroin-Assisted%20Treatment_(Feb.%202016).pdf

11. Oviedo-Joekes E, Brissette S, Marsh DC, et al. 

Diacetylmorphine versus methadone to treat opioid addiction.

12. Oviedo-Joekes E, Guh D, Brissette S, et al. 

Hydromorphone compared with diacetylmorphine for long-term opioid dependence: a randomized clinical trial.

13. Timko C, Schultz NR, Cucciare MA, et al. 

Retention in medication-assisted treatment for opiate dependence: a systematic review.

“It’s helped me a lot, just like to stay alive”: a qualitative analysis of outcomes of a novel hydromorphone tablet distribution program in Vancouver, Canada.

15. Behrends CN, Paone D, Nolan ML, et al. 

Estimated impact of supervised injection facilities on overdose fatalities and healthcare costs in New York City.

Harnessing Harm-Reduction Methods to Combat the Opioid Crisis

The US Food and Drug Administration (FDA), in partnership with the Duke-Margolis Center for Health Policy, plans to hold a virtual public workshop that will allow participants to provide input on the current opioid crisis and how it might be mitigated by requiring prescribers of opioids to complete education as part of a Risk Evaluation and Mitigation Strategy (REMS).

"Reconsidering Mandatory Opioid Prescriber Education Through a REMS in an Evolving Opioid Crisis,”

“The FDA recognizes that there may be new opportunities to improve prescriber education through the Opioid Analgesic Risk Evaluation and Mitigation Strategy and ensure that the education is being delivered in a way that minimizes the burden on the healthcare delivery system,” said Patrizia Cavazzoni, MD, director of the FDA’s Center for Drug Evaluation and Research. “The upcoming public workshop is the beginning of an important series of discussions with a broad group of stakeholders as the agency explores the value of mandatory opioid prescriber education on the appropriate use of opioids, the risks of opioid abuse and misuse and the treatment of opioid use disorder to address multiple needs and reduce the burden on prescribers.”

Topics to be discussed include the value of a single source for education on the appropriate use of opioids, risks of opioid abuse, and treatment of opioid use disorder. A wide variety of interventions intended to reduce inappropriate or unnecessary prescribing will also be evaluated.

Additionally, a second workshop is being planned to gather input on potential issues associated with a move to mandatory prescriber education under a REMS, like what operational and technical issues might arise with such a system, and what should be included in potential mandatory prescriber education.

“Opioid addiction and abuse remain a serious public health crisis and addressing it is among the FDA’s highest priorities. We will continue to explore new approaches that allow us to confront the crisis head-on,” said Cavazzoni.

What do you think? Will this move improve patient care and help address the opioid crisis? Share your thoughts via

1. US Food and Drug Administration. FDA in brief: FDA announces public workshop to reconsider mandatory prescriber education for opioids. News release. September 8, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-brief-fda-announces-public-workshop-reconsider-mandatory-prescriber-education-opioids?utm_medium=email&utm_source=govdelivery

The FDA is holding a workshop to discuss mandatory opioid prescriber education through the Opioid Analgesic Risk Evaluation and Mitigation Strategy. 

FDA Workshop Plans to Discuss Potential Mandatory Opioid Prescriber Education 

 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

Are benzodiazepine prescriptions contributing to the opioid overdose epidemic? 

Opioid Related Disorders