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Surgeon general: ‘We all pay the price’ for opioid epidemic

In the roughly 20 minutes U.S. Surgeon General Jerome Adams spent addressing law enforcement and health care leaders in Boston Thursday morning, two Americans would die of opioid overdoses, he told the crowd gathered in a Harvard Medical School conference room.

“The truth is, whenever anyone, anywhere, is suffering from substance use disorder from the opioid epidemic, it’s not just their problem,” Adams said at the Police Assisted Recovery Initiative National Law Enforcement Summit. “We all pay the price.”

Adams, who was appointed last year by President Donald Trump to the post that’s often described as the nation’s doctor, told the conference’s roughly 400 attendees that his three focal points in fighting the opioid addiction are prevention, education and the use of the drug naloxone, all areas touched on in recent Massachusetts laws.

US Surgeon General Jerome Adams

For Adams, an anesthesiologist who in his last post as Indiana’s state health commissioner led efforts to respond to an HIV outbreak there among injection drug users, the education piece revolves around both highlighting the severity of the epidemic and breaking down stigma.

He urged the crowd to join him in efforts to reduce the stigma of addiction, both by asking people “how we can meet their needs” and sharing personal stories.

Adams said his brother is in prison “due to crimes he committed to support his addiction” and has never been offered medication-assisted addiction treatment.

“We grew up in a rural area. My brother had to have someone drive him to get his drugs when he was at home,” Adams said.

“In prison, he said, they’ll deliver it right to your jail cell. It’s easier to get drugs in prison than what it is at home. That’s why it’s critical that we make treatment available for folks across the spectrum, wherever they are in the system.”

John Rosenthal, who co-chairs PAARI with Arlington Police Chief Fred Ryan, said addiction is a chronic disease without a cure, “but can be treated with love and compassion, with medication and community support.

“At the end of the day with the opioid epidemic, there’s only two choices,” he said. “Long-term treatment, or death.”

Rosenthal said overdoses killed 72,000 people last year across the country, and for every death, there are roughly nine saves with the overdose reversal drug Narcan.

In Massachusetts, where 1,518 people died of opioid overdoses in the first nine months of this year, the Department of Public Health this year issued a statewide standing order allowing pharmacies to dispense Narcan, known generically as naloxone, without a prescription.

Adams said making naloxone available to community members as well as first responders is critical because more than half of overdoses occur inside the home.

“Until we can invent an ambulance or a police car that can get across town in four minutes…we’re not going to dig ourselves out of this hole relying solely on first responders,” Adams said.

The standing order for naloxone was part of a law Gov. Charlie Baker signed in August. Also because of that law, Baker said Thursday, prisons and jails in Massachusetts “for the first time are going to be in the business of providing, on what I would call a focused and strategic basis, medication-assisted treatment.”

Governor Charlie Baker

Baker said there is still work to be done around addiction, especially with the rise of the powerful synthetic opioid fentanyl.

“I have had people say to me, now that you’re done with this, what else are you going to do? My answer is, I’m going to stay on this,” Baker said. “I’m going to stay on it. The next governor, whoever that is, is going to have to stay on it, the governor after that is going to have to stay on it.”

By Katie Lannan, State House News Service

Original article here posted on:

Family Happy Together

Parenting in Recovery: Breaking the Generational Cycle of Substance Abuse

Substance abuse and addiction can have long-lasting, rippling effects, especially in children exposed to drug and alcohol abuse in the home. Studies show relatives of people with alcohol abuse disorders are three times as likely to also abuse alcohol and two times as likely to abuse other illicit substances. Children are especially susceptible when it comes to substance abuse in the home and adult influences. 

NarcanInABox

Why You Might Not Be Able to Find Opioid Overdose Antidote at Your Pharmacy

It’s too easy to get opioid-based painkillers from pharmacies and too difficult to get medication used to treat overdoses from these drugs.

Those are the takeaways from a lawsuit filed in Florida against the CVS and Walgreens drugstore chains, as well as a new study that looked at the availability of the anti-overdose drug naloxone in two states that allow pharmacies to distribute the drug without a prescription.

Florida Attorney General Pam Bondi this week accused the companies of playing a role in creating the opioid crisis by failing to stop suspicious prescriptions of large quantities of opioid-based painkillers.

Bondi added the two drugstore chains to an existing lawsuit filed by the state against pharmaceutical companies that make opioid painkillers, including Purdue Pharma, maker of OxyContin.

A spokesperson for CVS said the lawsuit was “without merit,” pointing to steps that the chain has taken in recent years to restrict access to the drugs.

Prescription opioid drugs are widely misused. They were responsible for more than half of the 72,000 overdose deaths in the United States in 2017.

One way that states have tried to cut the death toll is to increase availability of the drug naloxone, sold as Narcan and Evzio.

Sold in injectable and inhaled forms, naloxone can rapidly reverse the effects of an opioid overdose.

When used as directed, the drug can prevent 75 to 100 percent of fatal overdoses.

In April, Surgeon General Jerome Adams said that “expanding the awareness and availability of this medication is a key part of the public health response to the opioid epidemic.”

Narcan has been widely distributed at harm-reduction sites, such as needle-exchange programs, and to emergency medicine technicians, firefighters, and police.

Many states have passed “Good Samaritan” laws that protect people who call police to assist with an overdose, even if they themselves have been using illicit drugs.

Antidote Availability

Nearly every state now allows pharmacists to distribute naloxone to customers without a prescription.

“When our pharmacists dispense naloxone, they counsel patients and caregivers on a number of important points, including identifying an overdose, the importance of calling 911, giving rescue breaths, administering naloxone, and remaining with the patient until help arrives,” Erin Shields, director of corporate communications for CVS, told Healthline.

CVS also offers coupons for naloxone that can bring the cost of a two-pack dose down below $100.

However, despite the blanket authorization offered by state “standing orders” — basically a statewide naloxone prescription that any pharmacist can use — a pair of studies published in the Journal of the American Medical Association found that many pharmacies either don’t dispense the drug to customers without a prescription or don’t have the drug in stock.

In California, for example, researcher Talia Puzantian of the Keck Graduate Institute and her colleagues found that less than 25 percent of about 1,150 retail pharmacies said they were giving naloxone to people without a doctor’s prescription.

Among those who said they did, less than 50 percent had the nasal version of naloxone in stock.

The Texas study, which focused on big-chain pharmacies such as CVS, Walgreens, and Rite-Aid, found better — but far from complete — compliance.

In that study, 84 percent of pharmacists said they would dispense naloxone, while 69 percent of pharmacies reported they had the medication in stock.

“The chain pharmacies are doing better than individual stores, but still these numbers are woefully low,” Puzantian told Healthline.

However, she stresses that availability of naloxone through pharmacies has improved, even in the months since the research in her study was conducted.

Expanding Access

The U.S. Food and Drug Administration (FDA) is looking at other ways to increase naloxone availability, including the development of a generic version of the drug.

Dr. Scott Gottlieb, the FDA commissioner, announced in October that the agency would host an advisory committee meeting in December to discuss ideas such as allowing naloxone — which has no potential for misuse — to be sold over the counter.

The overall number of naloxone prescriptions in the United States is currently quite low, Dr. Kimberly Sue, medical director of the Harm Reduction Coalition, told Healthline.

Sue says pharmacies have a critical role to play in widening distribution of naloxone.

She notes some countries allow pharmacies not only to distribute naloxone but also methadone and buprenorphine, two drugs used to treat opioid addiction.

Users of opioid drugs face a wide range of barriers to get treatment and potentially life-saving drugs like naloxone, Sue says.

However, pharmacies — many open 24 hours a day, seven days a week — are as ubiquitous as Starbucks in the United States and serve a broad spectrum of Americans.

“They could really be on the front lines in the opioid crisis, but so far they’ve been underutilized,” Sue said.

Written by Bob Curley on November 19, 2018

Original article here, posted on:

Library Books

8 Essential Books on Addiction and Recovery

“Not every story has a happy ending … but the discoveries of science, the teachings of the heart, and the revelations of the soul all assure us that no human being is ever beyond redemption. The possibility of renewal exists so long as life exists. How to support that possibility in others and in ourselves is the ultimate question.” -Gabor Maté, In the Realm of Hungry Ghosts: Close Encounters with Addiction

Books have been fundamental to my recovery from substance use disorder, codependency, mental illness, and complex PTSD. They’re more than just books: they contain the powerful stories of others who have walked my path, and they have given me a sense of hope that there is a fulfilling life beyond this condition. I love reading the words of expertise from physicians and clinicians who help us better understand the science of addiction. Perhaps most, though, I devour the work of journalists who have beautifully woven the words of science and experience to help us understand the relationship between trauma and addiction and how that impacts us physiologically and psychologically.

Woman Reading

These recovery-related books have given me the depth of insight into my illnesses that I would never have grasped in the rooms or the Big Book of Alcoholics Anonymous, or just with my physician’s intervention. It is with the knowledge I’ve gained from these books that I’ve empowered myself to self-direct a recovery and attain a life that I once felt was impossible.

This is by no means an exhaustive resource. It’s a curated list of the most powerful books that have impacted my recovery and the recovery processes of fellow writers, activists, and others in long-term recovery. While some of these books may not be specific to addiction, they contain potent insights into related conditions and circumstances.

  1. Childhood Disrupted: How Your Biography Becomes Your Biology and How you Can Heal by Donna Jackson Nakazawa.

This book has been the most insightful book that I’ve read throughout my nearly seven years in recovery. Nakazawa explains the groundbreaking Adverse Childhood Experiences Study, and the link between ACEs and chronic illness in later life, in a way that is powerful and easy to digest. Through storytelling, she shares the experiences of those who have overcome their adverse experiences and inspires the reader to reset their biology and heal.

  1. Nothing Good Can Come from This by Kristi Coulter.

I loved this book. Kristi Coulter is witty and smart, and relates to the topic of addiction in a masterful collection of dry, heartbreaking, and hilariously human collection of essays. I’m not alone in my admiration of her work — NGCCFT has been wildly successful. Fellow writer and editor Irina Gonzalez agrees:

“I’ve been waiting for Kristi’s book ever since I first read her essay ‘Enjoli’ early in my recovery and relating to it so much.” Gonzalez explains the appeal of Coulter’s narrative: “I loved her story because it’s very relatable — from her not having a huge ‘rock bottom’ to her writing about what happens after quitting drinking, two topics I don’t think are often talked about in other recovery/alcoholism memoirs. I actually loved the book SO much that I read it in two days! I found it very inspirational and very encouraging.”

  1. Unbroken Brain: A Revolutionary New Way of Understanding Addiction by Maia Szalavitz.

Maia Szalavitz is one of the world’s leading neuroscience and addiction journalists. In this book, she challenges the concept of a “broken brain” and an “addictive personality,” offering a radical and groundbreaking new perspective. In her book, she argues that addictions are learning disorders; by considering them in the context of this new paradigm, we can untangle our conflicting ideas around addiction treatment, prevention, and policy.

What I particularly like is her alternative perspective. I favor any outlook that stops us from believing that we are broken and instead focuses on an individualized approach and brings about healing.

  1. In the Realm of Hungry Ghosts: Close Encounters with Addiction by Gabor Maté, MD.

What I love about Gabor Maté is his approach to those who suffer with substance use disorders — it is one of empathy and understanding of the trauma that we have suffered. He brings together the science of addiction and his decades of experience as a doctor specializing in this condition. He adds another realm to what has always been considered to be a spiritual condition: evidence of trauma and stress.

“Not all addictions are rooted in abuse or trauma, but I do believe they can all be traced to painful experience. A hurt is at the centre of all addictive behaviors. It is present in the gambler, the Internet addict, the compulsive shopper and the workaholic. The wound may not be as deep and the ache not as excruciating, and it may even be entirely hidden — but it’s there. As we’ll see, the effects of early stress or adverse experiences directly shape both the psychology and the neurobiology of addiction in the brain.” – Gabor Maté

Man Reading

  1. The Body Keeps Score: Brain, Mind, and Body, In the Healing of Trauma by Bessel Van Der Kolk, MD.

Until the past few years, most addiction treatment focused on either retraining the mind or finding a spiritual solution. Few considered the physical element of recovery. In this fascinating book, Van Der Kolk explores the relationship between traumatic stress and its impact on the body, reshaping our body and brain and compromising our capacity for pleasure, engagement, self-control, and trust. This book is a must-read for those who want to heal their relationship with their body and the trauma stored within it.

  1. Recovery Rising: A Retrospective of Addiction Treatment and Recovery Advocacy by Bill White.

Renowned recovery advocate, visionary, and prolific author Bill White writes a professional memoir of the stories, reflection, and lessons learned throughout his journey. Many of those who work within the addiction treatment field have been reading the insightful words of White for the last five decades. His book has been touted as perceptive, revealing, and inspiring.

  1. The Recovering: Intoxication and Its Aftermath by Leslie Jamison.

Praised by most book fiends in recovery, The Recovering is a must read. In this memoir, Leslie Jamison navigates her personal story and interweaves the fascinating stories we tell about addiction together with the history of the recovery movement and its relationship with race and class. Her book has been described as “a transformative work showing that sometimes the recovery is more gripping than the addiction.”

  1. I’m Just Happy to Be Here: A Memoir of Renegade Mothering by Janelle Hanchett.

In 2011, Hanchett set up the website Renegade Mothering to find out if the rest of the mothering world is as crazy as she was. Having reached an audience of hundreds of thousands, she wrote about her experiences of seeking relief from motherhood in too much wine. Favored by many writers in recovery, her book has been described as wickedly funny and empowering, chronicling her journey through addiction into a recovery she didn’t know was possible.

What books helped you in early recovery? Add your favorite titles in the comments and we’ll check them out for our next list.

Written by: By Olivia Pennelle 12/05/18

Original article here on:

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Young man with hands clasped together

Can the Science of Addiction Ease Compassion Fatigue? | Opinion

New estimates from the Centers for Disease Control indicate 74,000 Americans died from drug overdoses in 2017, a 10 percent increase over 2016.Responding to the epidemic, Pennsylvania has made commendable efforts to increase the availability and use of naloxone to reverse opioid overdoses.  The widespread use of naloxone is a linchpin to an emerging decline in overdose deaths in well-equipped communities. In the past four years, Pennsylvania police officers have saved more than 7,600 lives by administering this life-saving medicine. Emergency medical personnel have revived thousands more.

First responders often receive repeated overdose calls for the same address or person. Understandably, this may lead to frustration with the seemingly endless cycle of addiction and apparent unwillingness of many overdose survivors to accept desperately needed treatment. Empathy for those with substance use disorders may diminish over time, often leading to compassion fatigue.

As both a physician and a person in long term recovery from an opioid use disorder, I have perspective as a care provider and as someone whose rational brain was hijacked by this progressive disease. I speak from painful experience when I say I truly believed my use of prescription painkillers was under control, even when it became glaringly obvious to others that it was not.

Eventually, I came to realize that all the medical training in the world could not have prepared me for the battle I faced.

As a physician, it was important to understand what happened to my brain. What compelled me to act in ways incompatible with my values, to lie to others and myself? Why did I have zero insight into my behaviors and their consequences? Why was my thinking so distorted? Why couldn’t I just stop?

Scientific research provides many answers to these questions and suggests why someone who is revived multiple times with naloxone—facing death repeatedly—refuses interventions and continues the harmful use of drugs.

In the brain, directly above our eyes, the frontal lobe controls our executive functioning. This includes rational, logical thinking and decision-making in line with our goals and values, as well as considering consequences and controlling social behavior.

Compare this to the more primitive middle portion of the brain where our survival (fight-or-flight), emotional and reward systems reside.

This part of the brain evolved early in human development to keep us safe from ancient predators. It instinctively and instantaneously revs up the body, compelling us to flee as fast as we can from a serious threat. We don’t think about it; we just run. If we wait until the rational frontal lobe assesses the threat, we could certainly become a lion’s lunch.

The brain’s rational, critically-thinking frontal lobe and its emotional, fight-or-flight mid-brain communicate constantly. When they’re in balance, the frontal lobe acts as the brake pedal for impulses, while the mid-brain acts as the gas pedal, propelling us to act on fears and perceived threats.

3d image of the brain

As a substance use disorder progresses, this delicate brain balance is lost, and communication between these two parts of the brain is significantly impaired. The rational frontal brain can no longer manage the impulsive mid-brain. The result is all “go” and no “stop.”

For people with an advanced substance use disorder, anything or anyone that comes between them and their substance of choice is perceived as the lion—an imminent threat.

The midbrain takes over as the analytic frontal lobe goes offline, and impulsive, irrational behavior can ensue. This often results in denial, ambivalence to or refusal of treatment and even aggression toward first responders.

Consider this: Why do lifeguards in training learn defensive maneuvers? Because a drowning person deprived of oxygen will claw his or her way over the rescuer with a singleness of purpose: to reach the surface for life-sustaining oxygen. It’s not personal; it’s an understandable human instinct.

When opioids become people’s oxygen, much like the drowning person, they will do whatever necessary to get the desperately needed substance, leading to sustained addiction.

My own desperation, negative consequences and ultimate hopelessness brought me to a breaking point, until I finally became willing to seek help.

In treatment, the opioids were purged from my system, and my rational brain started coming back online. I was able to gain insight into my addiction and begin my journey in recovery. The persistent compassion and encouragement of family and friends was vital to this process.

I understand why people, particularly first responders and health care professionals, may develop compassion fatigue during this opioid epidemic.

Still, I encourage them to consider the science—the “why” of addiction—when interacting with someone struggling with a substance use disorder. They make an impact every time they respond to an overdose call or interact with an overdose survivor. Their words and body language matter.

For people with a substance use disorder, disparaging words only compound their overwhelming shame and hopelessness; compassionate words plant a seed of hope that can blossom into long-term recovery.

If you or someone you know is struggling with addiction, this 24-hour hotline, staffed by trained professionals, will put you in touch with local services and support: 1-800-662-HELP (4357).

Dr. Jennifer Zampogna, M.D. is the director of operations for Lawyers Concerned for Lawyers of Pennsylvania, a non-profit organization that assists lawyers, judges, their family members and law students who are struggling with mental health and/or substance use issues.

Original article here.

Posted on https://www.pennlive.com/

Chatter Teeth

Study: Dental Painkillers May Put Young People at Risk of Opioid Addiction

Dentists who prescribe opioid painkillers to teenagers and young adults after pulling their wisdom teeth may be putting their patients at risk of addiction, a new study finds.

The study, published in JAMA Internal Medicine Monday, shines a light on the largely overlooked role dental prescriptions play in an epidemic of addiction that has swept the United States, leading to a record 70,237 drug overdose deaths in 2017.

“Given the gravity of the opioid epidemic, the degree of persistent use and abuse we observed in adolescents and young adults, especially females, is alarming,” said researcher Alan Schroeder, a pediatrician and professor at Stanford University School of Medicine. “Our findings should trigger heightened scrutiny over the frequency of prescribing dental opioids.”

Adolescents and young adults often are introduced to highly addictive opioid painkillers when they have their third molars pulled. Millions of Americans undergo the procedure every year, and dentists routinely prescribe opioids to the vast majority. Only recently have dentists — the most frequent prescribers of opioids for youths between the ages of 10 and 19 in 2009 — started to reconsider the use of narcotics in managing post-surgical pain.

Male Patient Female Dentist

Nearly 6 percent of almost 15,000 people between 16 and 25 years old who received initial opioid prescriptions in 2015 from dentists were diagnosed with opioid abuse within a year, the study published by Schroeder and four other researchers shows. In comparison, 0.4 percent in a similar group who didn’t get dental opioids were diagnosed with opioid abuse during the same period.

“These are kids who could have gotten Advil and Tylenol, and 6 percent showed evidence of becoming addicted,” said Andrew Kolodny, who co-directs opioid treatment research at Brandeis University. “That’s huge.”

The numbers are particularly troubling given that most people who have their wisdom teeth removed do just as well or better on over-the-counter pain relievers. An April study in the Journal of the American Dental Association found that anti-inflammatory analgesics, such as ibuprofen and acetaminophen, generally work better than opioids at easing acute dental pain.

“We certainly don’t need to expose adolescents to opioids after we take out their wisdom teeth,” said Kolodny, who was not involved with the study. “On that particular topic, the science is clear.”

Schroeder and his team examined the private health insurance claims of more than 750,000 patients from 16 to 25 years old. Close to 100,000, or a striking 13 percent, received at least one opioid prescription in 2015, and dental practitioners wrote 30 percent of them.

Schroeder assumes the bulk of the dental prescriptions were for wisdom-tooth extractions, though he had no way to determine why they were prescribed.

Of the almost 15,000 adolescents and young adults who received initial opioid prescriptions in 2015 from dentists, 6.9 percent received at least one more prescription three months to one year later — a red flag for persistent opioid use. Moreover, 5.8 percent were diagnosed with opioid abuse within a year of the first prescription.

The numbers looked especially troublesome for girls and women. More than 10 percent of female 16- to 25-year-olds who received a dental opioid prescription in 2015 were diagnosed with opioid abuse within the year.

“The key message here is we need to be careful with opioid prescribing from day one,” said Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.

“Your child’s receipt of opioids after a dental procedure may lead to long-term use or worse,” said Alexander, who was not involved with the study.

Kolodny called for a change in dental prescribing as a result of the new findings.

P. Angela Rake already has changed. Over the past two years, she has slashed the number of opioid pills she prescribes in her Minneapolis-area oral surgery practice.

She used to routinely prescribe 12 to 20 opioid pills to patients whose wisdom teeth she removed. Now she gives just half opioid prescriptions, and when she does, she prescribes half as many pills.

“Our prescribing patterns have greatly changed since 2015,” said Rake, a professor at the University of Minnesota School of Dentistry, who was not involved with the new study. “We have all reeducated ourselves and are in the process of changing prescribing patterns.”

Patient Smiling at Dentist

“When opioids were brought onto the market, we didn’t know the risks. Now we do,” she said.

Almost six times as many people died of opioid overdoses in 2017 than in 1999, when pharmaceutical companies began promoting opioids as a means to extinguish pain.

In general, opioid prescribing has declined “modestly” since 2015, Alexander said.

Another recent study examined the insurance claims of almost 71,000 people between the ages of 13 and 30. Those who filled opioid prescriptions following wisdom-tooth extractions from 2009 through 2015 were nearly three times more likely than those who didn’t take home opioids to be filling narcotic painkiller prescriptions long after any surgical pain should have subsided.

That study and the new one are consistent with research in hospitals and other clinical settings showing that a single prescription can set up patients for long-term use and abuse, Schroeder said.

“Historically, we’ve tended to underestimate how important the first opioid prescription can be,” Alexander said. “This new study shows that the first prescription may be terribly important because it’s a powerful predictor of long-term opioid use.”

“We’ve tended to overestimate the benefits of opioids and underestimate the risks in so many clinical settings at great cost to public health,” he said.

For years, health-care researchers ignored dental prescribing as a contributor to the opioid epidemic, Kolodny said. Initially, they focused on nonmedical drug use, keeping kids out of their grandparents’ medicine cabinets. When investigators turned to the problem of overprescribing, they looked first at chronic pain patients.

Studying dental prescribing has been complicated by dentistry being managed separately from other parts of the health-care system, Schroeder said. Most researchers have not had access to dental claims, he said. He used a medical database and searched for dental prescribers.

Researchers have no way to predict who might develop an opioid addiction. “This is one of the reasons that it is so important that we prevent the overuse of opioids in the first place,” Alexander said. “Wisdom-tooth removal is a classic example of where opioids have been overused, and, unfortunately, at great expense.”

December 3 at 11:00 AM

Original article here posted on:

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Study: More Expectant Moms Using Meth, Opioids

Meth and opioid use among expectant moms has grown significantly in the U.S. over a decade, a new study suggests, and the use is associated with worse outcomes compared with other baby deliveries.

The findings – published this week in the American Journal of Public Health – highlight the nation’s current drug crisis and appear to echo national trends in drug use.

“Basically what we found is amphetamine and opioid use disorders are increasing among delivering women in the U.S., and they’re increasing disproportionately across rural compared to urban counties across most of the United States,” says Dr. Lindsay Admon, an OB-GYN at Michigan Medicine Von Voigtlander Women’s Hospital and the lead author of the study.  “When we compared delivery-related outcomes, or birth outcomes, among moms with opioid and amphetamine use disorders, outcomes were actually much worse with methamphetamine use disorders compared to opioid use disorders.”

Baby in baby hat

Using data from the federal Agency for Healthcare Research and Quality, Admon and fellow researchers examined the trends in rates of amphetamine- and opioid-affected births in the U.S. from 2004 to 2015, drilling down to incidence by census region and among rural and urban residents.

The researchers noted that while they could not distinguish between methamphetamine use and other categories of amphetamine use, recent data show that “the majority (94 percent) of individuals with amphetamine use disorders seek care for methamphetamine-related use.”

The analysis revealed that from the 2008-2009 period to the 2014-2015 period, the estimated rate of amphetamine use among pregnant women across the U.S. doubled, from 1.2 per 1,000 hospital deliveries affected to 2.4. The rate of opioid-affected births more than quadrupled, from 1.5 per 1,000 deliveries to 6.5.

Researchers found that amphetamine- and opioid-related deliveries were both associated with worse health outcomes, longer lengths of stay and higher delivery costs than other hospital deliveries. Amphetamine-related deliveries were associated with higher rates of preeclampsia, placental abruption, preterm delivery and severe maternal morbidity and mortality than all other deliveries.

The adverse outcomes could be directly related to the drug use, researchers said, though they also noted that other factors may play a role. Substance use, for example, is associated with later prenatal care and fewer prenatal appointments, and access to treatment for pregnant women with addiction is often insufficient, especially in rural areas, the study said.

Higher rates for use of both amphetamines and opioids among pregnant women also varied by geographic location.

Happy baby

“By 2014 to 2015, amphetamine use disorder was identified among approximately 1 percent of deliveries in the rural Western United States, and that was higher than the incidence of opioid use in most other regions,” Admon says. Meanwhile, the incidence of opioid use disorder was estimated at 3 percent of all deliveries in the rural Northeast, higher than previously estimated, she says.

“When we looked into it, it’s been over 10 years since anybody has really looked at trends of amphetamine use, or methamphetamine use, in pregnancy, so these findings were really startling to us,” Admon says.

Still, Admon says she thinks her group’s estimates are probably conservative, as they rely on conditions such as clinicians screening for drug use, patients’ disclosure of substance use and proper recording of diagnoses.

“With substance use, it’s not just the opioid epidemic. There are other substances such as methamphetamine use that are also increasing, and I think we really need to think carefully about ways to connect women with the treatment resources that they need,” Admon says. “We have these really clear treatment guidelines for treating patients with opioid use disorder, and we don’t have the same type of guidance, certainly not in obstetrics, about how to best treat women with amphetamine use disorder, and I think there’s definitely a need for that.”

By Katelyn Newman, Staff WriterNov. 30, 2018, at 1:54 p.m.

Original article here posted on:

DrandPatient

Psychiatrists Can, Should Help Address the Opioid Epidemic

Psychiatrists and mental health professionals have a vital role to play in addressing the national opioid epidemic, according to a viewpoint published in JAMA Psychiatry.

“We believe psychiatrists are uniquely skilled and ideally suited to be leaders in treating this epidemic,” Srinivas B. Muvvala, MD, from Yale School of Medicine, and colleagues wrote.

“Psychiatrists are unique among physicians in having specialty training in treating trauma, depression, and other co-occurring psychiatric disorders and assessing suicidal behavior; increasingly, there is a growing awareness of the association between suicide and opioid use,” they continued. “Psychiatrists can provide integrated mental health care and relapse prevention counseling and therefore are uniquely qualified to provide office-based addiction treatments efficiently.”

In this viewpoint, Muvvala and colleagues argued that all psychiatrists should have training in assessing and treating patients with opioid use disorder. To respond to the epidemic, they recommended more psychiatrists complete the 8-hour training needed to prescribe buprenorphine, psychiatrists include buprenorphine treatment in routine psychiatric practice, and all residency programs require buprenorphine education for physicians in training.

WomanDiagnosingMan

Psychiatrists can incorporate buprenorphine treatment into outpatient practices easily and safely and recent evidence supports the safety and feasibility of physicians initiating buprenorphine treatment at home, according to the viewpoint. Mentoring programs are available to help physicians overcome any concerns when prescribing buprenorphine.

“Psychiatrists are in an excellent position to meet the requirement that buprenorphine be given in conjunction with psychosocial services,” Muvvala and colleagues wrote. “Psychiatrists can provide in-house counseling and also work collaboratively with other disciplines (eg, psychologists, social workers, nurses and counselors).”

In addition, Muvvala and colleagues wrote that U.S. general psychiatry residency programs are lacking in basic areas of training and only require 1 month of addiction treatment experience.

“Training programs need to broaden the exposure of residents to effective treatments in addiction, particularly in outpatient settings that include competency in prescribing medications for [opioid use disorder],” they wrote. “Buprenorphine training should be a required competency of psychiatry training.”

Ensuring that mental health clinicians know resources for training and mentoring psychiatrists to prescribe buprenorphine exist is critical, the authors wrote.

“Addressing the national opioid epidemic is the responsibility of every psychiatrist,” Muvvala and colleagues wrote. “With commitment and a modest investment in further training, the expertise of psychiatrists in treating other psychiatric disorders can be extended to the effective treatment of [opioid use disorder].” – by Savannah Demko

Disclosure: One author reports consulting for Alkermes; no other relevant financial disclosures were reported.

Muvvala SB, et al. JAMA Psychiatry. 2018;doi:10.1001/jamapsychiatry.2018.3123.

Original article here on Healio.com.

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Why Drug Deaths Are Down in Troubled Ohio

DAYTON, Ohio — Dr. Randy Marriott clicked open the daily report he gets on drug overdoses in the county. Only one in the last 24 hours — stunningly low compared to the long lists he used to scroll through last year in a grim morning routine.

“They just began to abruptly drop off,” said Marriott, who oversees the hand off of patients from local rescue squads to Premier Health, the region’s biggest hospital system.

Overdose deaths in Montgomery County, anchored by Dayton, have plunged this year, after a stretch so bad that the coroner’s office kept running out of space and having to rent refrigerated trailers. The county had 548 overdose deaths by Nov. 30 last year; this year there have been 250, a 54 percent decline.

Dayton, a hollowed-out manufacturing center at the juncture of two major interstates, had one of the highest opioid overdose death rates in the nation in 2017 and the worst in Ohio. Now, it may be at the leading edge of a waning phase of an epidemic that has killed hundreds of thousands of people in the United States over the last decade, including nearly 50,000 last year.

For the first time in years, the number of opioid deaths nationwide has begun to dip, according to preliminary data from the Centers for Disease Control and Prevention — with totals for the preceding 12 months falling slightly but steadily between December 2017 and April 2018. The flattening curve — along with declining opioid prescription rates and survey data suggesting far fewer Americans tried heroin last year and more got addiction treatment — is the first encouraging news in a while.

While it’s too soon to know if the improvement is part of a long-term trend, it is clear there are some lessons to be learned from Dayton. The New York Times spent several days here interviewing police and public health officials; doctors, nurses and other treatment providers; people recovering from opioid addiction and people who are still using heroin and other drugs.

They point to a variety of factors they believe have contributed to the sharp drop in mortality.

Medicaid Expansion Hugely Increased Access to Treatment

Mayor Nan Whaley thinks nothing has had as big an impact on overdose deaths as Gov. John Kasich’s decision to expand Medicaid in 2015, a move that gave nearly 700,000 low-income adults access to free addiction and mental health treatment.

In Dayton, that’s drawn more than a dozen new treatment providers in the last year alone, including residential programs and outpatient clinics that dispense methadone, buprenorphine and naltrexone, the three medications approved by the FDA to treat opioid addiction.

“It’s the basis for everything we’ve built regarding treatment,” Whaley said at City Hall. “If you’re a state that does not have Medicaid expansion, you can’t build a system for addressing this disease.”

An event held every other month at a church in Dayton’s East End shows the scope of available options. Called Conversations for Change, it gives people addicted to drugs a chance to have a meal and to meet treatment providers, who on a recent evening had set up more than a dozen tables.

“We have medication-assisted treatment programs, withdrawal management — come see me,” a representative for one program, Project Cure, urged the two dozen people present.

“If you’re interested in Narcan training, we’re going to get started in a few minutes — you can bring your food with you,” offered a representative of another program.

Kasich has said the state is spending $1 billion a year to address the opioid epidemic, and a big chunk of that is Medicaid funds. With Medicaid now paying for nearly all low-income residents who need it to get addiction treatment, Ohio has been able to go beyond the basics in spending its share of several billion dollars in the opioid grant money the Trump administration has been giving to states. One example: paying for people who go to jail and lose their Medicaid coverage to stay in treatment with their regular provider while they’re incarcerated.

Carfentanil, an Incredibly Toxic Fentanyl Analog, Has Faded

It’s entirely possible that the biggest factor in Dayton has been the dwindling presence on the streets of carfentanil — an analog of the synthetic opioid fentanyl that the CDC describes as 10,000 times more powerful than morphine. Ohio was particularly hammered by carfentanil in recent years; according to the CDC, the state had 1,106 carfentanil-related deaths from July 2016 through June 2017, compared with only 130 in nine other hard-hit states combined.

During that period, carfentanil was showing up regularly in Dayton’s street drugs, including methamphetamine, cocaine and fentanyl. Nobody has figured out why Ohio saw more of it than anywhere else, but there’s no question it played a huge role in the explosion of deaths in Dayton early last year.

By mid-2017 carfentanil’s presence was fading — maybe in part because traffickers realized how much of their customer base it was killing, said Timothy Plancon, the Drug Enforcement Administration special agent in charge of Ohio.

The news is not all good. Cocaine and particularly meth use is rising fast in the Dayton area, as it is nationwide. And they’re often mixed with fentanyl; 77 percent of the overdose deaths in Montgomery County from January through April involved fentanyl, roughly the same as during the same period last year. The national data also suggest overdoses involving fentanyl continue to rise, along with those involving cocaine and meth, while deaths involving heroin and prescription drugs are falling slightly.

Since late summer, deaths in Montgomery County have come closer to matching the same period last year — a reminder that the battle is far from over.

“I still go to more wakes than I care to tell you about,” said Lori Erion, founding president of Families of Addicts, a local support group. “Have we got this beat or licked? Absolutely not, on any level.”

Naloxone Is Everywhere

By now, most Americans have heard of naloxone — also known by the brand name Narcan — the medication that reverses opioid overdoses if administered quickly enough, by injection or nasal spray. But few Americans cities have blanketed their neighborhoods with naloxone like Dayton has.

Montgomery County agencies distributed 3,300 naloxone kits last year, and are on course to more than double that number this year, holding trainings at treatment centers and 12-step meetings as well as at local businesses and schools.

Two friends hugging

Starting in 2014, Richard Biehl, the Dayton police chief, directed all his officers to carry naloxone — going against some of his peers in other Ohio cities, including a sheriff in a neighboring county who outright refused to equip his deputies with it. Some in Ohio and elsewhere continue to oppose harm reduction tools like naloxone, saying they enable drug use, but the evidence is overwhelming that they save lives.

“We really jumped on it because we saw it as absolutely consistent with our public mission to save lives,” Biehl said.

Research suggests he was right. A recent study from Stanford estimated that wider availability of naloxone could prevent 21,000 deaths over the next decade — more than expanding access to medications for addiction or reducing painkiller prescriptions could. But as fentanyl analogs — whose chemical structure is slightly different and can be more lethal — started entering the drug supply in Dayton, it became harder to revive overdose victims with the standard dose of naloxone. So the city, with state support, has spent a lot more to provide higher doses — $350,000 last year.

The investment has paid off, said Helen Jones-Kelley, executive director of Alcohol, Drug Addiction and Mental Health Services for Montgomery County. “If nothing else, you get that second chance with them — and in some cases that third or fourth chance,” she said. “It gives people the opportunity to get connected to services, who would not otherwise have had that chance at life.”

There Is More Support for People When Treatment Ends

Even though there are many more treatment options here now, that doesn’t mean people stay in treatment as long as they should. But the city has an unusually large network of recovery support groups, including neighborhood clubs that provide space for Narcotics Anonymous meetings to Erion’s group, which has thousands of members in Montgomery and four surrounding counties.

Dayton is also investing heavily in peer support — training people who are far enough along in their recovery to work as coaches or mentors for others who are trying to stop using, including in emergency rooms. One example is an initiative called GROW — Getting Recovery Options Working — that dispatches teams of social workers, medics, police officers and people in recovery to homes of people who have recently overdosed. The teams offer to help them get into treatment and to drive them to a program. They also supply them and their families with naloxone to have on hand in case it’s needed.

“I just stop and plant a little seed,” said Darcy Shepherd, a peer supporter who went through treatment for opioid addiction almost five years ago. “I will pull up to them, ask how they are doing and if they are ready for treatment, and when they are, to give me a call.”

Joshua Lewis, 37, is among those who have managed to stay alive long enough to benefit from recovery supports. He overdosed repeatedly last year on heroin and fentanyl, while also using meth. His girlfriend found him a bed at a local treatment center, after which he spent three months at Joshua Recovery Ministries, a religious program that provides housing for men recovering from addiction. He learned how to read there, he said, and is now training to become a peer supporter. He doesn’t use medications for addiction but said he would not discourage others from doing so.

“There are more addicts coming out of the shadows,” he said. “The stigma’s being broke.”

Police and Public Health Workers Actually Agree

When Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,” testified before Congress earlier this year, he said that “the more cops and public health nurses go out for a beer, bridge that cultural chasm between them,” the better chance the country had at solving the problem.

Dayton has largely succeeded at bridging that chasm, which too often pits a punitive, abstinence-only approach to addiction against one that seeks to reduce deaths by any means possible. Law enforcement and public health representatives work hand in hand on a two-year-old Community Overdose Action Team, sharing data and strategizing with dozens of local organizations. Biehl was fully supportive of the city’s decision to set up a syringe exchange in 2014. Research has consistently found that such programs, which allow people who inject drugs to trade dirty needles for clean ones, prevent deaths related to infections like HIV, hepatitis C and endocarditis. While other cities, including Charleston, West Virginia, and Santa Ana, California, closed their needle exchanges this year because of opposition, including from the police, Dayton’s program continues to operate at two sites, each open once a week. The needle exchanges also help clients sign up for Medicaid and connect them with addiction treatment.

The city secured a federal grant for a pilot program that distributes fentanyl test strips, which can be used to check street drugs for the presence of various fentanyl analogues. Only a handful of cities are sanctioning the test strips at this point. Sheila Humphrey, the Dayton director for Harm Reduction Ohio, a nonprofit group, has given out thousands of strips, often at parks and community events.

“If it’s about conserving and protecting life,” Biehl said, “it has to be considered as an option.”

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By Abby Goodnough – The New York Times