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At the Annual Psychiatric Times World CME Conference, an all-star lineup of presenters will share their latest research. Check out this preview of the full agenda. 

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

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

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

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

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

Here are the AMA’s 7 recommendations for policymakers:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The AMA’s 7 Recommendations for Reducing the Opioid Crisis

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

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

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

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

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

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

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

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

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

Anti-Fentanyl Vaccines as Medical Solutions to Overdose Deaths

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 provides a summary of each of these novel treatments.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tackling the overdose crisis: the role of safe supply.

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

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

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

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

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

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

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

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

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

Comparing Canadian and the United States opioid agonist therapy policies.

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

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

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

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

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

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

Diacetylmorphine versus methadone to treat opioid addiction.

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

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

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

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

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

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

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

Harnessing Harm-Reduction Methods to Combat the Opioid Crisis

September 11, 2001 was a terrible day for New York City’s police officers, fire fighters, and other first responders. But not all of them registered trauma in the same way. Some of them developed posttraumatic stress syndrome quickly, while others had symptoms that emerged slowly, over years.

Frank Dowling, MD, has treated World Trade Center (WTC) first responders for decades, and they see parallels between the responders' experiences at Ground Zero and the experiences of physicians during the pandemic. Dowling hopes that what they have learned from 20 years of treating first responders can prepare the medical profession to meet the mental health challenges ahead.

(they/them) is a consulting psychiatrist at the Long Island World Trade Center Health Program at SUNY Stony Brook. They are the medical advisor to POPPA (Police Organization Providing Peer Assistance), a confidential assistance program for New York Police Department Officers.

Decades after September 11, 2001, many first responders still live with PTSD. Will the same be true of physicians who saw the worst of the pandemic?

Comparing COVID Doctors and 9/11 First Responders

Anniversaries help to define generations. Almost everyone can remember where they were when John F. Kennedy was shot, when the Space Shuttle Challenger exploded, and when the World Trade Center collapsed.

These anniversaries can bring patients’ the active symptoms of trauma, from anxiety and depression to panic attacks, anger, and substance use. But anniversaries can also be an occasion for post-traumatic growth. In this Mental Health Minute, Kenneth Yeager, PhD, MSW, LISW, talks about how to help patients reframe these situations—on September 11th or on any other important date.

is the director of the Stress, Trauma, and Resilience Program at the Ohio State University, where he is also a professor in the Department of Psychiatry at the College of Medicine.

How do you help patients handle difficult anniversaries? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

What can be done to help patients turn painful memories into opportunities for posttraumatic growth? 

The Anniversary Effect of 9/11

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

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

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

During the time period studied by Agarwal et al,

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

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

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

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

opioid overdose deaths are potentiated by BZDs

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

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

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

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

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

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

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

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

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

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

 and one such behavior is deceptive communication,

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

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

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

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

Patterns in outpatient benzodiazepine prescribing in the United States.

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

Benzodiazepine use and misuse among adults in the United States.

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

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

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

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

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

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

Integrated treatment of substance use and psychiatric disorders.

Are benzodiazepine prescriptions contributing to the opioid overdose epidemic? 

The Case for Caution When Prescribing Benzodiazepines 

In 2016, drug-related overdoses became the 

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

opioid-related overdose deaths have been a national epidemic

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Applicability to overdose prevention programs in other states

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

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

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

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

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

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

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

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

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

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

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

lower numbers of deaths compared to the national average

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

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

Substance Use Disorder