A Call for a ‘Peace Plan’ to Properly Treat Opioid Use Disorder

At the 2021 Rx Drug Abuse and Heroin Virtual Summit, IBH President Robert L. DuPont, MD presented a session entitled. “Combining Medications With 12-Step Model Treatment” that he co-presented with Marvin D. Seppala, MD, of the Hazelden Betty Ford Foundation, Center City, Minnesota. In a follow-up interview for the Rx Summit Newsroom, Dr. DuPont focuses on the need for a “peace plan” between substance use disorder treatment models that use and do not use medications.

Video Interview Part 1

Dr. DuPont discusses the 12‑step‑oriented model of addiction treatment and the need for it to “add medication as a fully respected, long-term option for patients with opioid use disorder”. He also discusses his goal to help the 2 treatment camps “stop fighting with each other” and his hopes that both can” work together in mutual respect”.

Video Interview Part 2

Polysubstance use in the U.S. Opioid Crisis

A new article co-authored by IBH President Robert L. DuPont, MD and Wilson M. Compton, MD, MPE and Rita J. Valentino of the National Institute on Drug Abuse (NIDA) urges new research on the prevalence and reasons for polysubstance use to inform and improve both the prevention and treatment of opioid use disorders. The current approach to substance use disorders (i.e., addiction) is substance-specific which neglects to address the common issue of polysubstance use.

Published in Molecular Psychiatry, authors highlight the overlap of substances used by American adults across the lifetime, noting, “as a general principal, the more widely a drug is used, the higher the percentage of users who do not use other drugs; and, the less widely used, the more likely a drug is to be used with other drugs.”

Fig. 1: Overlap of substances used across the lifetime. Weighted lifetime prevalence of substance use and mean number of other substances ever used by adults age 18 and older in the United States (n = 51,000; Source: 2018 U.S. National Survey on Drug Use and Health [adapted from Eric Wish, University of Maryland, Center for Substance Abuse Research]).

Abstract: Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

Compton, W.M., Valentino, R.J. & DuPont, R.L. (2021). Polysubstance use in the U.S. opioid crisis. Molecular Psychiatry, 26, 41–50. https://doi.org/10.1038/s41380-020-00949-3

Federal Judicial Center's The Opioid Crisis Series Features Robert L. DuPont, MD

The Federal Judicial Center, the research and education agency of the judicial branch of the US government, published The Opioid Crisis, a series of interviews related to the opioid misuse epidemic. The goal of this series is to provide federal judges and court personnel with information they can use in addressing one of the most destructive public health crises in our nation’s history.

Among the speakers features in the series is IBH President Robert L. DuPont, MD who shared insights from his 50+ years of experience on dealing with the issue.

The full series can be viewed online at the FJC website.

Dealing with the Addiction Crisis During the Nightmare of COVID-19

How do we deal with an addiction crisis during the nightmare of COVID? Individuals that suffer from substance use disorder (SUD) are facing even more challenges during COVID-19 as a vulnerable population that is experiencing isolation, loss of support, employment, food security, housing, transportation and safety issues. This stress and isolation have contributed to rising overdose deaths, up by as much as 42% compared to last year. Our addiction crisis is worsening during these unprecedented times and the impact to mental health is taking a toll on this population.

On November 17, 2020, the National Association of Drug Court Professionals (NADCP) and Averhealth sponsored a webinar to discuss the SUD epidemic prior to the pandemic, the current landscape, and offer solutions for how we can address these issues of social isolation, economic hardships and loss of support for those suffering with SUD.

IBH President Robert L. DuPont, MD presented alongside General Barry R. McCaffrey, U.S. Army (Retired) and Bertha Madras, PhD.

The recorded webinar can be watched online via Averhealth.

Linked National Crises: Overdose in the Time of COVID-19

***Click here to view or print a PDF copy of this commentary.***

Linked National Crises: Overdose in the Time of COVID-19

The global pandemic of COVID-19 threatens every nation, demanding urgent efforts to meet the changing health care needs of their populations. At the same time, the United States faces a concurrent epidemic of drug-related overdose deaths. The effects of COVID-19 are particularly severe for individuals and families facing substance use disorders. Considering substance use disorders and overdose deaths must be a part of the national response to COVID-19.

Prior to the COVID-19 pandemic, the number of overdose deaths in the US rose steadily from 1990 peaking in 2017 with over 70,000 overdose deaths. Largely because of an increase in overdose deaths and suicides, US life expectancy declined for three straight years, from 2015 to 2017– the first decline since 1918 when the nation faced the previously disastrous flu pandemic.¹ Overdoses were not a factor in the deaths recorded at that time. What is happening now is a new, and worrisome trend that threatens several years of focused national and local efforts to reduce overdose deaths. In 2018 the US experienced a modest decline in drug overdose deaths, with a drop to 68,557. New preliminary data from the Centers on Disease Control and Prevention shows that progress was lost. A new record in overdose deaths was set at 71,999 in 2019.^2,3 Data from the Overdose Detection Mapping Application Program (ODMAP) indicates that yet another new record will be set during the era of COVID-19.

ODMAP, which collects data on overdoses from communities across the country, reports that in 2020 all overdoses – both fatal and non-fatal – increased compared to the same months in 2019: an 18% increase in March, a 29% increase in April, and a 42% increase in May.^4,5,3 Other national indicators suggest that illicit drug use is increasing. Following the March 13, 2020 declaration of COVID-19 as a national emergency, urine drug testing positivity rates showed statistically significant increases for fentanyl, methamphetamine, and cocaine.⁶ The positivity rate for heroin also increased but did not reach statistical significance.

We are losing the limited but important progress previously made in the battle to curb the overdose epidemic for several reasons. First, the drug supply is lucrative, widespread, and adaptable to COVID-19 related changes in the marketplace. Second, the COVID-19 pandemic has hindered significantly and even closed many inpatient and outpatient substance use disorder treatment programs. Third, the pandemic has incapacitated many community-based recovery support networks including, but not limited to, Twelve Step fellowships of Alcoholics Anonymous and Narcotics Anonymous. Fourth, substance use is often social, but it is also solitary; the broad isolation the population faces during COVID-19 may increase substance use and subsequent risk of overdose. As warned by Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), “Social distancing will increase the likelihood of opioid overdoses happening when there are no observers who can administer naloxone to reverse them and thus when they are more likely to result in fatalities.”⁷ Perhaps not surprisingly, a comparison of overdoses reported to ODMAP during pre-stay-at-home orders and post-stay-at-home orders in 2020 showed a 17.5% increase in all fatal and non-fatal overdoses.⁵

What can be done about the national rise in overdose rates?

• Use discussions of COVID-19 to highlight the problem of addiction, which is often solitary and hidden. Encourage families and others to intervene strongly when their loved ones are actively engaged in substance use. Get them into treatment and engaged in recovery support.
• Recognize the added threats of relapse even among those in recovery from substance use disorders in the time of COVID-19.
• Use media outlets aggressively to educate the public about the health threat posed by substance use, the warning signs of overdoses, and how to access and use naloxone to reverse an opioid overdose.
• Fund substance use disorder treatment and support programs as they innovate care during the COVID-19 pandemic. The American Medical Association recently outlined several action steps⁸ for states to take, including adopting rules and guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA)⁹ and Drug Enforcement Administration (DEA)¹⁰ for programs that treat individuals with opioid use disorders.

As the nation faces the linked crises of the COVID-19 pandemic and a resurgence in overdoses, we must identify, protect, and assist those who are the most vulnerable. This includes individuals with substance use problems.¹¹

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References

[1] Woolf, S. H., & Shoomaker, H. (2019, November 26). Life expectancy and mortality rates in the United States, 1959-2017. JAMA, 322(20), 1996-2016. doi:10.1001/jama.2019.16932

[2] Ahmad, F. B., Rossen, L. M. & Sutton, P. (2020). Provisional drug overdose death counts. National Center for Health Statistics, US Center for Disease Control and Prevention. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[3] Katz, J., Goodnough, A., & Sanger-Katz, M. (2020, July 15). In shadow of epidemic, U.S. drug overdose deaths resurge to record. The New York Times. Available: https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html

[4] Wan, W., & Long, H. (2020, July 1). ‘Cries for help’: drug overdoses are soaring during the coronavirus pandemic. The Washington Post. Available: https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/

[5] Alter, A., & Yeager, C. (2020, June). COVID-19 impacts on US national overdoses. Overdose Detection Mapping Application Program. Available: http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf

[6] Millennium Health. (2020, July). COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic. Millennium Health Signals Report volume 2.1. Available: https://resource.millenniumhealth.com/signalsreportCOVID

[7] Volkow, N.D. (2020, April 2). Collision of the COVID-19 and addiction epidemics. Annals of Internal Medicine, 173(1), 61-62. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138334/

[8] American Medical Association. (2020, July 8). Issue brief: reports of increases in opioid-related overdose and other concerns during COVID pandemic. AMA Advocacy Resource Center. Available: https://www.ama-assn.org/system/files/2020-07/issue-brief-increases-in-opioid-related-overdose.pdf

[9] Substance Abuse and Mental Health Services Administration. (2020, March 19). Opioid treatment program (OTP) guidance. Available: https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf

[10] Drug Enforcement Administration. (2020, March 31). Prevoznik, Thomas W. Letter to DEA Qualifying Practitioners and DEA Qualifying Other Practitioners. Available: https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%20+Esign.pdf

[11] Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the Covid-19 pandemic. New England Journal of Medicine. Available: https://www.nejm.org/doi/full/10.1056/NEJMp2008017

Should physicians with opioid use disorders be offered an option of opioid agonist treatment?

A new article published in the Journal of the Neurological Sciences reviews neuropsychological impairment associated with substance use by physicians; describes common neurocognitive deficits following use of various drug classes; and reviews the neurocognitive impact of pharmaceutical treatments for opioid use disorder (OUD). Authors emphasize the importance of continued testing/monitoring for physicians with substance use disorders (SUDs) following acute treatment.

In response to this review article, Robert L. DuPont, MD and Mark S. Gold, MD authored a commentary published in Clinical Psychiatry News, noting that to understand the controversy over the use of medication-assisted treatment (MAT) in the care management of physicians with OUDs requires: 

• An understanding of state PHPs and how those programs oversee the care of physicians diagnosed with SUDs, including OUDs; 

• Recognition that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job; and

• An understanding of the historical context of the unique system of care management for physicians which began in the early 1970s.

"Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery. The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field." Read more.