Hero

Videos

Slideshows

Articles

Podcasts

Poll

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

First Participant Joins Opioid Use Disorder Treatment Study 

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

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

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

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

Opioid Use Patterns During the Civil War Era

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

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

physicians’ prescriptions or their medical advice

 Opiates were standard remedies for hundreds of ailments (

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

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

opium was “the ‘Magnum Dei Donum’”

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

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

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

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

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

Black Civil War Soldiers and Opiate Addiction

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

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

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

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

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

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

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

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

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

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

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

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 illness. 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, 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

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. Like Black Civil War veterans in the late 19th century, African Americans today have less access to prescription opioid painkillers than White Americans. Persistent racial disparities in opioid prescribing rates have been so extreme that, until recently, White Americans were about 

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

 Considered in the historical context, however, 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 White Americans, 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 long-standing, 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.

is postdoctoral scholar, George and Ann Richards Civil War Era Center, Pennsylvania State University, State College, Pennsylvania. His website is 

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

and Frank Clark, MD, Inclusivity and Diversity Editor for

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

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

6. Humphreys M. Marrow of Tragedy: The Health Crisis of the American Civil War. Johns Hopkins University Press; 2013.

7. A Manual of Military Surgery. Prepared for the Use of the Confederate States Army. 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. N C Med J. 1885;15-16:206-207.

10. Tipton F. The negro problem from a medical standpoint. New York Med J. 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

12. Sommerville DM. Aberration of Mind: Suicide and Suffering in the Civil War-Era South, University of North Carolina; 2018:85-88.

13. Owens DC. Medical Bondage: Race, Gender, and the Origins of American Gynecology. The University of Georgia Press; 2017.

14. Versalle F. Washington, Eagles on Their Buttons: A Black Infantry Regiment in the Civil War. University of Missouri Press; 1999:22-23.

15. Humphreys H. Intensely Human: The Health of the Black Soldier in the American Civil War. Johns Hopkins University Press; 2008:11.

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

19. Wailoo K. Pain: A Political History. Johns Hopkins University Press; 2014:194-195.

A ‘rare case where racial biases’ protected African-Americans

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

The Opioid Addiction Crisis and Racism: A Long, Troubled History

Precision medicine took another step forward as Adial Pharmaceuticals announced their intent to enter the genetic testing market. The news comes after the company received a Notice of Allowance from the US Patent and Trademark Office related to use of their genetic diagnostic panel in combination with their lead product, 

“This new patent related to the use of our genetic diagnostic panel in combination with AD04 for the treatment of AUD and OUD is a major milestone as we believe genetic evaluation of patients can be used to identify individuals that may benefit from AD04. We have been utilizing the genetic panel covered by this patent in our ongoing ONWARD™ Phase 3 trial, and, given this patent allowance, we anticipate that genetic diagnostics are expected to be an important segment of our commercial strategy going forward,” Adial’s CEO, William Stilley, said in a statement to the press. “Our view that AUD has a solid nexus in genetics is fundamental to the premise of the successful Phase 2B trial of AD04 conducted at the University of Virginia and our ONWARD™ Phase 3 trial of AD04 currently underway in Europe. And, it is consistent with Adial’s premise that the presence of certain genetics is expected to substantially influence whether an individual suffering from AUD or OUD would likely respond to treatment with AD04.”

 is a genetically targeted therapeutic agent for the treatment of AUD. The drug is designed to reduce cravings thereby reducing alcohol intake. patients curb their drinking. The oral medication will not require abstinence before or during treatment. To date, it has shown positive safety and tolerability profiles.

Once issued, the patent is anticipated to provide market exclusivity for the AD04 genetic diagnostic test. With this in mind, Adial plans to enter the genetic testing market as a stand-alone commercial business line and market the genetic diagnostic panel as a Companion Diagnostic Test to AD04. Approximately one-third (33%) of AUD patients are expected to respond to treatment with AD04.

In addition to the benefits for patients, the resulting efficacy may also realize cost savings to the health care industry. “Market research conducted by Adial indicates a willingness among payors to reimburse a genetic companion diagnostic test, and this may allow Adial to provide patients personalized, precision medicine and also potentially provide dramatic cost savings to payors,” Stilley said further.

1. Adial Pharmaceuticals. Adial Pharmaceuticals plans to enter genetic testing market following allowance of US Patent for genetic diagnostic test. News release. June 22, 2021. Accessed June 22, 2021. 

https://ir.adialpharma.com/press-releases/detail/122/adial-pharmaceuticals-plans-to-enter-genetic-testing-market

2. Adial Pharmaceuticals. Technology. Accessed June 22, 2021. 

Adial’s AD04 for the treatment of alcohol use disorder received a Notice of Allowance from the US Patent and Trademark Office. 

Patent Brings Psychiatry One Step Closer to Precision Medicine

North America is currently experiencing an opioid overdose crisis driven mainly by fentanyl and fentanyl analogs, such as carfentanyl.

fatalities involving opioids in the United States

 The COVID-19 pandemic has only heightened the 

 of opioids on individuals who use the drugs, their families, and communities across 

 Novel solutions are needed for this complex problem.

Much is already being done. In an effort 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 antagonist naltrexone, 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 

 Although buprenorphine/naloxone is preferable over methadone in terms of its superior safety profile, there are many limitations to these treatments. Moreover, in Canada, there are barriers to accessing OAT, including reduced access to OAT prescribers in rural areas, and the shortage of pharmacies offering on-site OAT.

OAT clinics often lack psychosocial supports, and there are often high out-of-pocket expenses that 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, health insurance barriers, where public insurance providers favour methadone while private insurance favours buprenorphine/

, have caused rampant racial and economic disparities in OAT access across the United States.

Since the start of the opioid crisis, Canada has taken several novel harm reduction approaches to combat the opioid crisis. Harm reduction refers to a wide array of public health policies intended to reduce the adverse consequences of human behaviours, including—but not limited to—substance use. In the context of the opioid crisis, harm reduction interventions have included rapid access addiction medicine services, providing 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, there is mounting evidence that 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 amongst individuals with treatment-refractory OUD (TR-OUD).

In recent years the Canadian health care providers have implemented 3 critical harm reduction measures that have curtailed opioid-related fatalities: (1) heroin-assisted therapy, (2) hydromorphone-assisted therapy, and (3) supervised consumption facilities (SCFs). A summary of each of these novel treatments is provided in 

Following the Canadian example, we advocate for the provision of 

 in the United States that could save countless lives by increasing access to evidence-based treatment options for OUD.

Heroin-assisted treatment (HAT), or heroin maintenance, is an evidence-based intervention for managing the symptoms of treatment-refractory OUD (TR-OUD). While there are varying definitions of TR-OUD, 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 in 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 must visit designated 

, where they will 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 overdoses11 than methadone or buprenorphine/naloxone. While 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, Canada, 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 one of the first to establish the efficacy of these harm reduction measures for a population of individuals with TR-OUD. Consequently, the SALOME trial suggests 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 promising results of the SALOME trial. A qualitative study evaluated its effects, suggesting that it can decrease illicit drug use, overdose risk, engagement in illegal activities, and address social inequalities surrounding drug use.

, take-home hydromorphone has been permitted, and the effects of this expansion can be promising for the wide-scale implementation of similar programs in rural, suburban, and urban settings.

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

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

 SCFs have emerged in Canadian cities such as Toronto, Ottawa, and Halifax as grassroots initiatives to address unmet needs for special populations with TR-OUD or other substance use disorders. These SCF initiatives can also assist in different ways by providing counselling and psychosocial supports, referrals to social services, and access to medical and psychiatric treatment where 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 

 One of the additional benefits of SCFs is that they can provide a multifaceted opportunity to address comorbidities, such as psychiatric illness, HIV/AIDS, and other infectious diseases. As individuals with TR-OUD frequently experience co-occurring medical and psychiatric disorders, SCFs have created critical opportunities to engage with a population that is difficult to reach otherwise. Various studies have demonstrated their myriad benefits, such as decreasing 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. It showed that an SCF can prevent 19 to 37 opioid overdose fatalities per year in New York City and between $831,700 and $2.9 million in costs would be saved by the healthcare system.

 However, this remains a controversial topic in the United States, and advocacy for drug policy changes must continue.

The overdose crisis 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 Northeast, Mid-Atlantic, and Mid-Western states being most impacted.

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

 (> 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 most commonly used opioid agonist therapies (OAT) in Canada and the United States are methadone and buprenorphine/naloxone. However, their availabilities vary across regions and by insurance coverage.

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 at high risk of 

. These can be powerful aids to reducing the harm of fentanyl-related opioids from the illicit drug market, and as a result, prevent overdose events and decrease overdose mortality.

 Canadian and international SCF studies have shown effectiveness in reducing overdose fatalities and decreasing needle sharing, unsafe injection practices, and involvement in criminal activities.

 As Canada and the United States take action to combat the current opioid crisis, they can learn from the collective expertise and strategies implemented on either side of the border to search for comprehensive, collaborative, and evidence-based approaches to the opioid crisis.

is a 3rd-year medical student at Touro College of Osteopathic Medicine in New York, NY, USA.

is a Fellow in Addiction Psychiatry in the Cumming School of Medicine at the University of Calgary, Calgary, Canada.

is a Staff Psychiatrist in the Addictions Division at the Centre for Addiction and Mental Health (CAMH) and 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, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

is Professor of Psychiatry in the Temerty Faculty of Medicine at the University of Toronto, and Clinician-Scientist in the Addictions Division at CAMH in Toronto, Canada. He also serves as Deputy Editor of the journal Neuropsychopharmacology (NPP).

The constructive and critical comments of Dr Eric C. Strain 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. Government of Canada. Opioid- and Stimulant-related Harms in Canada (Maps). Accessed March 24, 2021. 

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

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

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

4. Government of Canada. (March 24, 2021). Opioid- and Stimulant-related Harms in Canada (Key Findings). 

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

5. Centers for Disease Control and Prevention. Overdose deaths accelerating during COVID-19 – expanded prevention efforts needed. December 18, 2020. 

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

6. Schuckit MA. Treatment of opioid-use disorders. 

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. 

9. Young S, Fairbairn N. Expanding supervised injection facilities across Canada: lessons from the Vancouver experience. 

10. Drug Policy Alliance. Heroin assisted treatment (HAT). February 2016. 

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. 

14. Ivsins A, Boyd J, Mayer S, et al. "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. 

How can understanding the opioid crisis in Canada inform strategies in the United States?

Lessons from Novel Harm Reduction Methods

“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.”

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

Opioid Related Disorders

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

First Participant Joins Opioid Use Disorder Treatment Study

The Opioid Addiction Crisis and Racism: A Long, Troubled History

Patent Brings Psychiatry One Step Closer to Precision Medicine

Lessons from Novel Harm Reduction Methods

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

Addressing the Opioid Crisis: A New Approval

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

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

Improving Care in Teens With Opioid Use Disorder