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Tales From the Clinic: The Art of Psychiatry

Tales From The Clinic: The Art of Psychiatry,

 we follow the story of a young man who turned his life around for the sake of his spouse and child, but nevertheless struggled with the tribulations of normal upheaval. Recovery from 

 does not protect against normal life events, but our patients are more sensitive to stress than their nonsubstance user counterparts, increasing the potential for stigmatization. We visit the moral versus brain disease model of addictive processes through the case, and hope to help readers appreciate their own biases and open themselves to understanding the neurobiology of addiction. The aim of proper diagnosis and treatment is to have an objective conception of addiction rather than a morally framed conversation, when behaviors related to addiction are viewed through a negative prism.

“Mr Wallace” is a young man with opioid use disorder and major depressive disorder. He lost contact with his wife and young child as a consequence of his 

. His wife moved to another country, prompting him to get treatment “like I really mean it this time.” He gained sobriety on medication-assisted treatment (buprenorphine/naloxone) and did well, earning advanced certification in his field and increasing his earnings significantly. He also took up the hobby of synthetic music. His wife returned with their child, with subsequent stabilization of the relationship, the purchase of a house, and other life milestones.

The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.”

 Although NIDA adheres to the brain disease model of addiction (

), there continues to be controversy surrounding whether addiction is a disease or a matter of choice. If addiction is viewed as a moral failing, as posited by the moral model of addiction, then there is the belief that the patient is responsible for their substance use and at fault for having a character defect or a weakness of will.

Advancements in neuroscience have made it possible to identify strong genetic, neurodevelopmental, and sociocultural components of addiction. Evidence pointing to the activation of reinforcement circuits (

) by drugs through the neurotransmitter dopamine in brain areas, such as the nucleus accumbens and ventral tegmental area, further supports irreversible changes in the brain’s structure and function resulting from substance use.

 Because of these permanent changes, it is postulated that individuals cannot exercise self-control over their behavior pertaining to addiction.

This biological approach, supported by animal models of addiction,

 has made room for pharmaceutical treatments of 

. This approach also supports liberation from the belief that addiction is a moral lapse in individuals who have deep character flaws. The disease model of addiction has often been assumed to diminish the attribution of free will to those with drug addictions, which could possibly have significant implications in the attribution of responsibility and stigma as well as the acceptance of treatment.

Critics of the purely brain disease model of addiction believe that categorizing substance use as a disease may further stigmatize individuals with addiction and prevent them from developing self-control, all while damaging their self-esteem.

 and simply diseasing addiction will only further stigmatize those who suffer from addictions. While proponents of the brain disease model of addiction believe adherence to this model will encourage treatment-seeking behaviors, critics believe it will erode the confidence of addicted individuals in their ability to overcome addiction if it is inherently viewed as permanent structural and functional changes in the brain. Research on addictions such as smoking finds that attribution of addiction to unchangeable intrinsic factors leads to lower levels of quitting intentions and quitting self-efficacy.

 Naysayers of the brain disease model of addiction also point out that a clear majority of addicted individuals recover naturally without requiring medical interventions.

Opponents of the brain disease model of addiction believe it: is insufficiently supported by animal-model and neuroimaging data; has only a modest impact on public policies toward drugs and addiction; and has not majorly contributed to the development of more effective treatments despite the decades of research.

 Evidence to support environmental approaches to reducing substance use cautions strongly against the possibility of policy makers and government officials being enticed by the allure of 

. There is some concern that an overly biological emphasis on addiction could take attention away from the necessary social and environmental interventions and divert resources to the production of expensive and perhaps risky medical interventions that can realistically only be accessed by a certain population. 

Proponents of the brain disease model of addiction postulate that adherence will encourage seeking of evidence-based medical assistance to overcome a brain disease. They believe this model lends itself to a collaborative approach between patients and physicians against addiction. However, critics believe the brain disease model of addiction lends itself to addicted individuals absolving themselves of personal responsibility. This results in infantilizing individuals with addictions while shifting the responsibility of overcoming addiction to medical professionals.

 This stark difference in how each model contributes to the physician-patient relationship sheds light on the topic of countertransference (

Mr Wallace later found out—after buying the house, buying a car, and moving back in with his wife and child—that his wife had not been faithful. This led to significant use of Adderall by Mr Wallace and ongoing relationship issues. He continues to have interpersonal issues in the relationship and struggles with maintaining the relationship for the sake of keeping access to his daughter.

, not only does the relationship between the clinician and the patient play a role, but so do the thoughts, beliefs, and experiences of the physician. Besides the brain disease model of addiction, there are several other models that seek to explain the development of substance use. The moral model describes addiction as resulting from a character flaw or moral failing; the choice model sees drug use as a voluntary but harmful behavior; and the psychosocial model regards substance use as related to economic, cultural, and other social factors.

These lead to beliefs about who claims responsibility for beginning and overcoming 

, including the medical model, which regards patients as requiring medical treatment and having low responsibility for the presence and resolution of use; the moral model, which places all responsibility on the patient; the enlightenment model, which states that the individual is responsible for the problem but not the solution; and the compensatory model, which states that the individual is not responsible for the problem but is responsible for the solution.

From studies on treatment providers’ views on the brain disease model of addiction, there seems to be overall support for this concept, although with variations noted among different professions of providers. The strongest support was generally seen in psychiatrists, especially those who were older.

 Interestingly, there was significant evidence of an amalgamation of beliefs, with providers expressing support for multiple models and levels of patient responsibility. These findings extended from treatment providers to treatment settings as well, with examples provided of substance as a “self-induced disease,” bringing together the requirement for medical treatment with responsibility for the initiation and resolution of use belonging to the individual.

 This appears to reflect the complexity of 

 and its treatment, and suggests that the conceptualization of substance use may be tailored to the needs of a particular patient or to the needs of the patient population seeking treatment in a specific setting.

How a physician conceptualizes substance use plays a role in the countertransference experienced. Thinking a patient is willfully making bad choices will obviously decrease positive feelings or wanting to help them, or to go the extra mile in treatment planning. On the other hand, approaching substance use from the brain disease model of addiction helps patients overcome stigma and reduce guilt, as use is not conceptualized as a moral failure of the patient. This may help reduce negative countertransference toward patients with substance use by assisting in understanding frustrating, demanding, or confrontational behavior as not intentional or specifically directed at the provider. Negative countertransference could result in direct consequences, such as avoidance of the patient, difficulty with empathetic responses, and sessions cut short.

This could also increase protective or parental feelings toward patients, especially if they are viewed as helpless against the structural and chemical factors that contribute to their use.

 Such a “positive” countertransference can also lead to difficulty in the therapeutic relationship, as the clinician may take on the role of a parent, becoming overly engaged, protective, and permissive. If the patient then regresses and begins to act out or relapses, the clinician may feel betrayed and subsequently have difficulty in future encounters with the patient. A parental countertransference may also result in the clinician infantilizing the patient and minimizing their strengths and abilities.

 As with all forms of countertransference, the ability to identify and label the ensuing emotion is as critical as the adjustments the clinician must accordingly make.

Although there are many frequently underutilized medications for substance use disorder, a mainstay of treatment relies on naturalistic options such as Alcoholics Anonymous, Narcotics Anonymous, inpatient and outpatient rehabilitation programs, and similar offerings. The Anonymous groups generally involve a 12-step approach that includes concepts of acknowledging addiction as well as the difficulty in overcoming it, recognizing wrongs, making amends for those shortcomings, committing to a life with continued focus on sustained abstinence, and working to help others, especially those experiencing similar struggles with substance use (

Historically, and continuing in the present day, these programs tend to have a strong spiritual component to them, which can be off-putting for some individuals and make it harder to engage. Of the limited data available, there is evidence for the beneficial effect of involvement in 12-step programs for maintaining sobriety, both with and without attending a rehabilitation program. The impact seems to be strongest for those who started attending 12-step groups prior to entering a rehabilitation program and who continued to be involved after completion of rehabilitation. Most of the available evidence is in regard to alcohol use, with less data focused on other substances.

Medicine is far from the conceptualization of addiction as a sin, yet the belief in biological models still lags considerably, as evidenced by suboptimal prescribing of anti-craving medications. In general, evidence-based practices for addiction treatment are still not fully implemented at the scale they could be, and this is likely reflective of how addictive diseases are conceptualized in everyday practice.

is a psychiatry resident at Baylor College of Medicine. 

 is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation.

is an addiction psychiatrist at Baylor College of Medicine and the director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System in Houston, Texas.

1. National Institute on Drug Abuse; National Institutes of Health. Drugs, brains, and behavior: the science of addiction. 2007. Accessed March 15, 2022. 

https://nida.nih.gov/sites/default/files/soa.pdf

Brain disease or biopsychosocial model in addiction? Remembering the Vietnam Veteran Study.

The science of making drug-addicted animals.

Free will and the brain disease model of addiction: the not so seductive allure of neuroscience and its modest impact on the attribution of free will to people with an addiction.

Addiction and moralization: the role of the underlying model of addiction.

6. Harackiewicz JM, Sansone C, Blair LW, et al. 

Attributional processes in behavior change and maintenance: smoking cessation and continued abstinence.

The brain disease model of addiction: is it supported by the evidence and has it delivered on its promises?

Drug and alcohol treatment providers’ views about the disease model of addiction and its impact on clinical practice: a systematic review.

Countertransferential and attitudinal considerations in the treatment of drug abuse and addiction.

11. Thomas S, Monico N. The 12 steps of Alcoholics Anonymous. American Addiction Centers. Updated December 20, 2021. Accessed March 15, 2022. 

https://www.alcohol.org/alcoholics-anonymous/

Recovery from addiction does not protect against normal life events...

Normal Life Stress, They Say…

The following poster presentations at the American Pharmacists Association (APhA) Annual Meeting & Exposition highlighted a number of changes facing psychiatry today.

Concurrent Benzodiazepine, Opioid Use Risks

Because more than 30% of overdoses involve a combination of benzodiazepines and 

, and more than 115 Americans die from opioid overdose every day, the investigators conducted this study to assess how much patients know about the increased risk of adverse events, overdose, and death associated with taking 

 and opioids concurrently. They also focused on the role of education, surveying study participants both before and after educational intervention. The study included 9 participants (33% male; 66% female; median age 59 years) who had been prescribed a benzodiazepine (Xanax [alprazolam], 77%; Klonopin [clonazepam], 22%; or Ativan [lorazepam], 11%) and an opioid (Norco [hydrocodone/acetaminophen], 55%; Percocet [oxycodone/acetaminophen], 22%; Roxicodone [oxycodone], 11%; or Roxanol [morphine sulfate], 11%). Participants were surveyed both before and after receiving information detailing the increased risks associated with concurrent benzodiazepine and opioid use. Each survey asked them to rank their knowledge of the medications, the potential adverse effects and 

 risk of the medications, and the risks of alcohol consumption on a scale from “unaware” to “minimal” to “good” to “excellent.”

In the presurvey, each knowledge category was divided among “excellent,” “good,” and “unaware” rankings, with “minimal” only appearing in the knowledge of overdose category at a little over 20%. Most participants ranked their knowledge as “excellent” in only the knowledge of medications category (a little more than 40%), with “good” leading the rankings in the potential adverse effects and alcohol consumption categories nearly 60% and a little more than 40%, respectively. Around 20% of participants ranked their knowledge as “unaware” across all 4 knowledge categories. In the postsurvey, no participants ranked their knowledge as “unaware” or “minimal” in any category. In both the knowledge of medications and the potential adverse effects categories, patients ranked their knowledge as “good” or “excellent” at around 80% and around 20%, respectively. In knowledge of 

, the majority of participants (around 90%) ranked their knowledge as “excellent,” with the remaining 10% ranking it as “good,” and 100% of participants ranked their knowledge of overdose—the category with the most varied results in the presurvey—as “excellent.”

Although patient education resulted in clear improvement of self-reported knowledge and understanding, only 1 participant changed their medication regimen to lower the risks of adverse events. According to the investigators, this means that patients are reluctant to change their prescribed medications even with greater awareness of the risks.

“Overall, patients can have a good baseline knowledge, but the results of this study demonstrate how pharmacists can further improve patient understanding… and knowledge of the medications [patients] are currently prescribed,” the investigators concluded.

In their poster presentation, Kafi Friday, BA, PharmD candidate 2023; and Prashant Sakharkar, PharmD, MPH, explained that sexual minorities, or individuals with nonheterosexual sexual orientation, face increasing challenges in achieving health equity, due to stigma and discrimination.

 Via a retrospective cohort study, the investigators sought to examine health disparities and level of depression among 

; compare the prevalence of sexually transmitted infections, 

, illicit drug use, and alcohol use in use in sexual minorities; and determine predictors of depression among sexual minorities.

The study’s results painted a grim picture for sexual minorities: sexual minorities were 3 times more likely to have gonorrhea and chlamydia infection, 65% more likely to use illicit drugs, 52% more likely to be a smoker, 3 times more likely to experience 

, and 2 times more likely to see a mental health clinician.

These findings suggest that depression can be a consequence of health and behavioral disparities. Screening—particularly in females who identify as a sexual minority, smoke, use illicit drugs, are under the age of 45, and are poor—might help in early intervention. Furthermore, the investigators noted future research should examine the association of depression, 

Want to learn more on the advances in psychiatry? Join us this August at the 2022 Annual 

™ World CME Conference. For more information and to register, visit 

1. Baciu A, Negussie Y, Geller A,alWeinstein JN, eds. 

Communities in Action: Pathways to Health Equity.

Catch up on all the latest from the American Pharmacists Association (APhA) Annual Meeting & Exposition.

APhA Conference Addresses Depression, Benzos

What is the current state of the opioid epidemic, and what role does naloxone play in the emergency treatment of patients with known or suspected opioid overdose?

These questions and more were addressed in this installment of the custom Around the Practice video program. Panelists for this important discussion included Matthew A. Torrington, MD; Daniel E. Buffington, PharmD, MBA; Thomas R. Kosten, MD; and Bill H. McCarberg, MD.

“This is not a new epidemic,” said Kosten, adding the opioid crisis started as early as 2015. “One can say it was led by the overprescribing of opiates, but what has taken over [the expanding crisis] is fentanyl.”

The panel agreed it has spread across age groups, making it everyone’s problem.

Naloxone may be a solution, Buffington explained, but it may need to be administered several times to counter opioid overdose in emergency situations due to the “increased prevalence of higher-potency fentanyl products” in recent years.

A 27-year-old man presents for evaluation in extreme pain from a car accident. He has a past history significant for substance use disorder, high blood pressure, and diabetes. He takes buprenorphine 2 mg, lisinopril 20 mg, and metformin 500 mg per day. During the next 4 hours, his pain levels vary. Imaging shows a broken ankle, a broken rib, and a small hairline fracture on his clavicle; a CT and MRI show no tissue or brain damage. He gets a cast for his ankle and is started on low-dose opioid therapy—1 oxycodone acetaminophen every 4 to 6 hours as needed for pain for 5 days, until he can see his primary care provider.

This is where the real problems begin, the panel agreed, as the patient is discharged without appropriate pain management. “If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose,” explained Torrington. “I see as a lot of this substandard pain treatment, which makes people—even reasonable people—go to the illicit market to get something else to help them with their discomfort... If we don’t do an adequate job, they’ll take matters into their own hands.”

Acknowledging that this patient is at risk for overdose, the panel discussed the potential use of naloxone.

Kosten recommended 8 mg of naloxone, stating, “If he did go to the illicit market, unfortunately, fentanyl might be in that and you’re going to need a big dose of naloxone to do something.”

McCarberg agreed that this patient is a good candidate for naloxone. “This person has an opioid use disorder—I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it was a subtherapeutic dose,” he explained. “He’s still drinking, he’s smoking cigarettes, all of which put him at high risk for going outside of the standard prescribing realm to get medication...So he really is high risk given all of these factors together. This is the guy that needs the naloxone and a discussion with the wife or whoever’s the other members of the family about what to look out for if he overdoses.”

A 49-year-old unemployed male truck driver is found semiresponsive, and an opioid overdose is suspected. He has a past medical history of high blood pressure, diabetes, obesity, and chronic pain, as well as opioid use following a previous motor vehicle accident. He smokes 1 pack of cigarettes a day, is recently divorced, and lost his job during the pandemic. During the physical exam, he is hypertensive and unresponsive to sternal rub. During the clinical work-up, he has pinpoint pupils, has gone pale, and has clammy skin. His blood pressure is 60/40 mm Hg. His heart rate is 28 beats per minute.

After confirming his airway is clear, he is given supportive breathing and then 8 mg of naloxone intranasally. He is monitored for opioid withdrawal and/or non–naloxone resistance.

“I think you have to think about longer-term treatment,” Kosten said. “Based on the 8 mg of naloxone that it took to reverse him and what is on the street, he probably did get fentanyl in his system. Then the question is: What do you want to treat him with? Could you treat him with naltrexone?” Kosten posed. “An injectable naltrexone lasts a month, so you do not have compliance problems. If he is not opiate dependent, that’s a real possibility.”

“This person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges,” Torrington added. “There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not that much else happens.”

The panel noted it was important to involve the family to prevent negative outcomes.

“I had a recent overdose rescue in my practice, and what struck me was that the wife said, ‘I didn’t know if I should give it or not. I couldn’t tell.’ The question comes up: Should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, error on the side of something that is less harmful to the patient.”

The panel further agreed that to keep patients off the streets looking for medications, care needs to go beyond undertreating pain.

Kosten concluded: “[Providers] have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent—that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.”

is a board-certified family medicine and addiction medicine physician practicing in Culver City, CA. Mr Buffington is president and CEO at Clinical Pharmacology Services in Tampa, FL.

is the Jay H. Waggoner Endowed Chair and professor of psychiatry, pharmacology, immunology, and neuroscience, as well as vice-chair for psychiatry, and codirector of the Dan L. Duncan Institute for Clinical and Translational Research, and a professor of at the Baylor College of Medicine in Houston, TX. He is also on the editorial board for

is founder of the Chronic Pain Management Program for Kaiser Permanente and adjunct assistant clinical professor at the University of California San Diego School of Medicine.

If you missed out on the custom Around the Practice video program on naloxone, we've got you covered. Read a recap here. 

Naloxone as a Tool to Fight the Opioid Epidemic

The use of opiates and resulting overdoses continue to grow.

 Research shows that medications can be useful for curbing cravings and preventing the misuse of narcotics.

 Even though medications have proven helpful, the lack of motivation to change and the incentives for diversion limit treatment compliance.

 Individuals’ inaccurate and unhelpful beliefs about themselves and about substances often interfere with positive change.

 Cognitive behavior therapy (CBT) has been found to be helpful when used together with medication-assisted treatment (MAT).

One of the problems individuals experience when misusing substances is the powerful immediate reinforcement they receive from taking the substance. Indeed, one of the primary reasons people use substances is the immediate reinforcement which, in the moment, is much more compelling than the long-term negative consequences of continued use. By the time most individuals voluntarily talk to an addiction specialist, they have likely experienced negative consequences, including diminished pleasure, negative side effects, and negative social consequences.

Individuals who come to treatment are often conflicted. On one hand, they have experienced negative consequences; on the other hand, they are unable to imagine that their lives could be different or better. In CBT, we work with individuals to help them change the trajectory of their lives by placing a renewed focus on the things they value. We help them imagine how their own lives could improve if they were to pursue aspirations that are aligned with their personal values. When individuals place a renewed focus on their values and personal aspirations, they can connect the short-term and long-term consequences of their actions. Individuals find motivation to change their old habits and participate in healthier activities.

With a newfound desire to make changes in their lives, individuals need to make what are often difficult decisions. In CBT, we support individuals in making decisions by doing a cost/benefit analysis. The cost/benefit analysis helps elucidate the relative positive and negative elements of engaging and not engaging in a particular action. By conducting a cost/benefit analysis, individuals gain clarity about the things they value. Accordingly, individuals may make decisions about people with whom it is in their interests to associate, which places to frequent to further their goals, and what things they can do to help them move in a positive direction.

In the throes of addiction, individuals often lose their ability to manage their schedules. In CBT, we help individuals develop schedules with a focus on 2 types of activities. One type of activity increases their level of mastery of things they either need to do or want to do. These activities could include everything from basic hygiene to developing expertise in a profession. The second type of activity increases a person’s experience of pleasure, without engaging in substance use. Individuals who suffer from addiction have often lost their ability to experience pleasure when not using drugs. A CBT therapist will help individuals select activities that match their interests and include them on a master schedule designed to include all the different activities they need to do. Having scheduled activities allows less time for the individual to seek out and use substances. The feelings of mastery and pleasure serve as positive reinforcement for engaging in the various activities.

When individuals are caught up in the dynamics of addiction, they often develop negative beliefs about themselves and their abilities. This can lead them to have negative expectations that become self-fulfilling prophesies when situations play out as they predicted. After a person engages in activities that increase their level of competence and pleasure, they gather evidence that contradicts their formerly held beliefs about themselves and about substances. The newly acquired evidence starts a cycle of reinforcement based upon positive assessment, statements, and feelings about themselves. Repeatedly engaging in activities that give them a sense of competence and/or pleasure, combined with positive experiences, lays the foundation for creating new beliefs about their capabilities and capacity for positive feelings.

The continuous use of substances over an extended period can cause a person to become numb to life’s events. Once an individual gives up using substances, the renewed experience of having feelings can be unnerving. Managing emotions can become an important target for therapy. Developing a routine sleep schedule, engaging in healthier eating, and moderating physical elements of emotions may all help an individual learn to better control their feelings. Relaxation techniques, mindfulness exercises, or other activities such as yoga, prayer, and meditation can be very effective ways of helping people tolerate and manage their experience of feeling emotions that they have not felt for a long time. These techniques can be used with people from all walks of life and with varying histories related to substance misuse.

“Maria” was a 22-year-old college student when she was referred for treatment following her arrest for drug possession and distribution. Maria had excelled academically and in multiple sports during high school. She went to college on a softball scholarship and planned to become a physical therapist. Following her freshman year, Maria tore her rotator cuff. Initially, she thought it was a minor injury and continued to play and work out. The tear got worse and, despite surgery, ended her ability to play softball at the college level. The injury was devastating to Maria because not only could she no longer play sports, but she lost her scholarship, had continuous pain and disrupted sleep, and became depressed as a result. She struggled to keep up with her studies. Her greatest relief from the physical pain and emotional upset was the oxycodone she was given following surgery. Her depression made it difficult for her to fully engage in treatment, and although her doctor recommended ibuprofen and alternative treatments, she continued to request the medication. After several months, her doctors discontinued the opiate medication.

Maria, in the meantime, had connected with others who were able to provide street drugs to fill her increasingly greater need for relief. When she was cut off by her doctors, she turned immediately to her friends. Eventually, she expanded her network of people from whom she could acquire and with whom she would share drugs. This eventually led to her arrest. Maria’s relationship with her parents and her old friends suffered along the way, and her parents were very concerned about her. They expressed a desire to help her find solutions. Maria’s attorney referred her for CBT treatment after her arrest and before any court appearances.

Initially, Maria was friendly and expressed a desire to participate in treatment. She was quite clear, though, that she did not know how to get along without opioids. Maria felt responsible for getting herself into her current predicament and felt helpless; she thought her future was hopeless and that she had lost any measure of worth. Rather than reminding her of what she had lost or lecturing her about the consequences of her continued drug use, we started therapy by focusing on the things that were important to her before her injury. Sports, academics, family, and friends were always important to her. They all seemed intricately linked to one another, and her injury seemed to take away everything she cared about.

Acknowledging the losses and the difficulties she had experienced, we talked about what her life could be like if she was able to reclaim the things she valued. Her family and academics were still important to her, and although she could not play softball, she was still capable of exercising. In session, we had her imagine that she finished school, renewed her relationship with her parents, and engaged in tolerable levels of exercise. She did not believe that she could be a physical therapist and switched her major to occupational therapy. Her vision of her aspiration served as a strong motivator to get her life back on track.

Still, Maria could not consistently resist her cravings for drugs. We taught her relaxation exercises that she found helpful for her emotional state and calming her urges, but they were not universally effective. We talked about the possibility of medication to help with her cravings. She and her parents had concerns about relying on medications to resolve medication issues, but after doing a cost/benefit analysis of the advantages and disadvantages of trying the medication versus the advantages and disadvantages of not trying the medication, Maria decided to give it a try. The medication had both agonist and antagonistic properties that worked well for controlling her urges and, to some extent, helped with her lingering pain. With those benefits, we then discussed other alternative treatments for pain that included ibuprofen and physical therapy. When Maria gained control of her urges with medication, she felt stronger.

After receiving relief from physical pain and urges to use, Maria was better able to concentrate on achieving her desired life. Initially, she found it challenging to manage her time. We worked together on an activity schedule to make time for her classes and homework. For Maria, it was important that she have a schedule that made time for her parents and other supportive friends, exercise, a routine sleep schedule, and healthy eating. As she followed her schedule and became more active, she felt more confident and competent. She changed the way she thought about herself. Rather than thinking of herself as being helpless and worthless, she recognized the power she had to do many good things with her life and felt increasing more worthwhile as a person.

It had been 3 to 4 years after Maria’s rotator cuff injury when she was referred for CBT treatment. Simply stated, for a variety of reasons, she had deviated from her previously successful path in life. With about 12 months of CBT and medication, she was able to get her life back on course. At that point, she had been accepted into an Accelerated Rehabilitation Disposition (ARD) program of the court, had completed her bachelor’s degree, and was accepted into a master’s program in occupational therapy. She was still taking her medication, but did not want to have to take it forever. She exercised, but did not get the same level of pleasure as she did from playing high-level competitive sports and was still working on accepting that she could not do what she did before. She was making new, supportive friends whom she liked, although when she saw her old teammates, she experienced sadness that she could not be one of them. Maria maintained her values in life and took major steps toward achieving her aspirations. One thing she recognized was the need for her to continue using the tools she learned to stay on her path of recovery.

Cognitive and behavioral strategies can be useful in treating opioid use disorder, either on their own or in conjunction with medication. Alone, or with medication, CBT can improve motivation, aid in important decision-making, jumpstart behavioral activation, and facilitate the development of new beliefs about drugs, oneself, and the future. Medication can help patients control their urges so they can better focus on the work of therapy.

 is a seasoned clinician, trainer, and administrator who provides oversight to the training and clinical services at Beck Institute as the CBT program director. For more than 25 years, he held leadership positions in a large integrated health system, including roles as director of behavioral health at WellSpan Behavioral Health, as chair of psychology for a 580-bed acute care hospital, and as chief psychologist for an APA-approved internship in clinical psychology that he founded. As a clinician, Dr Miller has used CBT to help individuals of all ages with a myriad of presenting problems coming from forensic, community, educational, and medical settings. He has conducted workshops, written professional articles, and published several resource books for lay readers about personality, depression, anxiety, and stress.

1. Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. Press Release. November 17, 2021. Accessed March 24, 2022. 

https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm

2. Substance abuse and addiction statistics. National Center for Drug Abuse Statistics. February 19, 2022. Accessed March 24, 2022. 

3. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Medication-Assisted Treatment for Opioid Use Disorder. The effectiveness of medication-based treatment for opioid use disorder. In 

Medications for Opioid Use Disorder Save Lives

. Eds. Mancher M, Leshner AI. National Academies Press. 2019.

4. Alfonsson S, Johansson K, Uddling J, Hursti T. 

Differences in motivation and adherence to a prescribed assignment after face-to-face and online psychoeducation: an experimental study

Effectiveness of the cognitive restructuring approach on irrational beliefs and hopelessness in individuals with a substance abuse disorder: a randomized controlled trial

7. Ray LA, Meredith LR, Kiluk BD, et nal. 

Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders: a systematic review and meta-analysis

8. Moore BA, Fiellin DA, Cutter CJ, et al. 

Cognitive behavioral therapy improves treatment outcomes for prescription opioid users in primary care buprenorphine treatment

Cognitive behavioral therapy for substance use disorders

How can this combination of treatments help create positive change for individuals struggling with addiction?

Cognitive Behavior Therapy and Medication-Assisted Treatment for Opioid Use Disorder

At the American Pharmacists Association 2022 Annual Meeting and Exposition, one poster titled “Youth Opioid Safety Knowledge and Perceived Impact of an Educational Game: A Nationally Representative Sample,” explored the importance of adolescent’s perception of dangerously addictive opioids. Claire A. Rosenberger; Olufunmilola Abraham, PhD, MS, BPharm; Jen Birstler, MS; and Kathleen Tierney demonstrated how an educational game could be used to improve opioid awareness in young people.

Using a 67-item questionnaire, the investigators surveyed 592 American youths aged 12 to 18 about their existing knowledge of opioids. Sample questions included “Have you heard of the drug naloxone (Narcan)?” and “Is it ok to take someone else’s opioid medication if you had the same prescription in the past?”

One question posed to the young participants asked, “Is the opioid crisis harming teenagers in the US?” Nearly 500 participants said yes.

When asked if an educational video game would increase their awareness of opioid medication safety, more than 450 of the participants said yes.

Results showed differences in opioid knowledge among different gender, race, grade, and age. Most adolescents knew the opioid epidemic is harmful, but many were unaware of naloxone. The investigators concluded that future studies should investigate the use of an educational game to educate adolescents on opioid safety.

Can a game improve children and adolescents knowledge of the opioid crisis? 

Fun and Games: Improving Youth Opioid Awareness

John J. Miller, MD, relays the tragic story of a heroin user in this week's video on the opioid crisis. 

The Opioid Epidemic Is Alive—And Unwell

 is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter; consulting psychiatrist, Exeter Hospital, Exeter; and consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Playing with opioids is a dangerous game...

The Illicit Fentanyl Russian Roulette

John J. Miller, MD, shares concern and information about the alarming opioid overdose epidemic in America. The numbers of overdose deaths in 2021 is expected to spike above 100,000. 

This is the sad reality: In the first year of COVID-19, there were 20,000 more opioid overdose deaths than years previous. 

The Centers for Disease Control and Prevention (CDC) recently reported that more than 100,000 people in the United States died of overdose in the 12 months ending April 2020. In response, the Drug Policy Alliance (DPA), National Harm Reduction Coalition, and People’s Action and VOCAL-NY led a group of 240 civil rights, drug policy, criminal justice reform, public health, and faith-based organizations in urging members of Congress to pass legislation that will prioritize the beating the 

They specifically urged Congress to consider evidence-based public health approaches, including critical harm reduction funding, the MAT Act, the STOP Fentanyl Act, and the Medicaid Reentry Act.

“With over 100,000 people dying of overdose in the US during the first year of the pandemic, passing these critical pieces of legislation is not only more urgent than ever before—it’s literally a matter of life and death for so many people,” said Maritza Perez, Director of the Office of National Affairs at the Drug Policy Alliance. “We are far past the point of waiting for a politically convenient time to take the necessary steps to curb this crisis and save lives. The US Government has targeted and criminalized our communities for drugs over the last 50 years as a political ploy which has only fueled the overdose crisis. With countless more lives at stake, it’s time to stop playing politics and continuing down this ill-fated path. It is absolutely imperative that policymakers change course immediately and prioritize evidence-based public health alternatives that are proven to actually save lives.”

Their statement urges Congress to enact life-saving legislation by the end of the 2022, including the following 4 items:

1. $69.5 million in funding to increase access to overdose prevention, harm reduction, and syringe service programs through the CDC’s Infectious Diseases and the Opioid Epidemic program.

2. The Mainstreaming Addiction Treatment Act, which eliminates the outdated requirement that practitioners apply for a separate waiver through the Drug Enforcement Administration to prescribe 

 for the treatment of substance use disorders.

3. The Support, Treatment, and Overdose Prevention of Fentanyl Act, or the STOP Fentanyl Act, which improves fentanyl surveillance and detection.

4. The Medicaid Reentry Act, which would allow Medicaid to cover health services during the last 30 days of incarceration and create better linkages to community-based care during reentry.

—through evidence-based, public health solutions,” said Sondra Youdelman, People’s Action Campaigns Director. “Our communities just suffered a record-breaking 100,000 preventable overdose deaths in a single year. Instead of continuing to criminalize drug use, Congress needs to take evidenced-based action now, and listen to the people who lost 100,000 loved ones.”

Jasmine Budnella, Director of Drug Policy at VOCAL-NY, echoed these sentiments: “Our nation is at a heartbreaking, infuriating watershed moment. With over 100,000 of our loved ones dying from a preventable overdose, it is a grave failure that evidence-based solutions proven to turn the tide on the overdose crisis remain out of reach. Congress must heed the calls for urgent action, and pass legislation rooted in science, harm reduction, and care before the new year. If our leaders fail to act, another year of devastating and historic overdose deaths is inevitable.”

1. Drug Policy Alliance. As overdose crisis claims record lives, coalition of 240 organizations urge Congress to pass lifesaving public health bills. News release. November 30, 2021. Accessed December 1, 2021. 

https://drugpolicy.org/press-release/2021/11/overdose-crisis-claims-record-lives-coalition-240-organizations-urge-congress

A coalition of 240 organizations came together to urge Congress to pass legislation to fight the opioid crisis. 

Stopping the Opioid Crisis: Evidence-Based Public Health Approaches 

“Ms Rose” is a 63-year-old African-American female with schizoaffective disorder. Her psychotic disorder has been stable on ziprasidone, venlafaxine, and zolpidem as needed. She had surgical repair of a torn rotator cuff and was prescribed opioids (oxycodone) for postoperative pain. Two weeks later, her husband found her on the porch, unresponsive and not following commands. She was brought to the local 

 by ambulance. Work-up for acute stroke and other causes of altered mental status was negative/unremarkable. Her discharge diagnosis was orthostatic hypotension secondary to medication polypharmacy, and she was advised to discontinue opioids.

 in the United States are filled by patients with comorbid mental health disorders, including patients with concomitant antipsychotic use.

 Compared to the general population, patients with severe mental illness are 2.5 times more likely to be treated with opioids for chronic pain.

 In 2016, the US Food and Drug Administration (FDA) issued a black-box warning about the combined use of opioids and antipsychotics due to risks of respiratory depression.

 However, there is substantial heterogeneity amongst individual antipsychotics in regards to sedative properties and the potential for respiratory depression, which is mediated through antagonism of histamine-1 receptors.

 Risks of overdose in patients co-prescribed opioids and sedating versus nonsedating antipsychotics has not been investigated.

 investigated this association in a population-based cohort. The authors studied patients aged 15 to 85 who filled an opioid prescription between 2004 and 2017, nested in the IBM MarketScan Commercial and Medicare supplemental claims database.

The investigators identified all individuals who filled a prescription for an antipsychotic (index date). Other inclusion criteria were continuous medical and prescription drug benefit coverage for 180 days before the index date, no evidence of 

, and at least 1 opioid prescription filled within 14 days preceding the index date. Antipsychotics were classified as sedating (eg, chlorpromazine, clozapine, olanzapine, and quetiapine) and nonsedating (eg, aripiprazole, haloperidol, lurasidone, risperidone, and ziprasidone) based on histamine-1 receptor affinity (

The primary outcome measure was emergency department visit or 

 due to an overdose even within 30 days of the index date. Patients were followed until the occurrence of the outcome, death, end of the study, or 30 days, whichever came first. Szmulewicz et al compared baseline characteristics between patients receiving opioids and sedating versus nonsedating antipsychotics using propensity score matching. Incidence rates (IRs) and their 95% confidence intervals (CIs) were calculated for each exposure group. Hazard ratios (HRs) and 95% CIs were estimated with Cox proportional hazard models. 

After 1:1 propensity score matching, the cohort consisted of 62,604 patients newly exposed to a sedating antipsychotic plus opioids (“exposed”) and an equal number of patients newly exposed to a nonsedating antipsychotic plus opioids (“referent”). Mean patient age was 50, and 33% of the cohort was male. The most commonly prescribed opioids were hydrocodone, oxycodone, tramadol, and buprenorphine. The IR of overdose was 35 events per 1000 person-years in the exposed group, and 26 events per 1000 person-years in the referent group, corresponding to an adjust HR of 1.34 (95% CI 1.07-1.68). In sensitivity analyses, there was evidence for a dose-response relationship based on antipsychotic dosage. Findings were consistent across a number of other sensitivity and subgroup analyses.

The authors concluded that among patients receiving prescription 

, sedating antipsychotics are associated with an increased risk (up to 60%) of unintended overdose compared to nonsedating antipsychotics. Findings support the FDA black-box warning about the combined use of opioids and antipsychotics.

Strengths of the present study include the large sample size, consideration of many potential confounders, use of an active comparator, and multiple sensitivity analyses. Limitations include the observational study design, the potential for medication nonadherence during the follow-up period, and the use of a commercially insured population, and that fatal unintentional overdoses prior to hospitalization would have been missed.

Clinicians should consider the risk of unintentional overdose when prescribing 

 to patients taking opioids. Depending on the clinical situation, use of nonsedating antipsychotics may help mitigate this risk.

is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

Prescription opioid use among adults with mental health disorders in the United States.

2. FDA Drug Safety Communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning. FDA. March 2019. Accessed October 26, 2021. 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-serious-risks-and-death-when-combining-opioid-pain-or

Receptor-binding profiles of antipsychotics: clinical strategies when switching between agents.

4. Szmulewicz AG, Bateman BT, Levin R, et al. 

Risk of overdose associated with co-prescription of antipsychtoics and opioids: a population-based cohort study.

Unintentional overdose with antipsychotics plus opioids. Researchers performed a population-based cohort study of the risk of overdose associated with co-prescription of antipsychotics and opioids.

Opioid Related Disorders