Thursday, March 7, 2019

Deaths of Despair at Highest Levels Ever!

From the Well Being Trust:

Far too many Americans are dying from preventable causes, and each time we make progress it seems like new problems appear. Take the case of opioid overdoses. As we are beginning to get a handle on misuse of prescription opioids, fentanyl and synthetic opioids have come to the fore. Two decades ago, they were linked to fewer than 1,000 deaths each year. In 2017, fentanyl and synthetic opioids killed more than 28,000 Americans.
The emphasis on opioids is appropriate, but too narrow. The underlying conditions that often lead to drug misuse can also lead to alcohol misuse, loneliness, and despair. Even as America is experiencing surging rates of drug misuse, the nation is also witnessing an unprecedented rate of suicide deaths, which rose 6 percent between 2016 and 2017, and with alarming increases among children and adolescents.
Overall, more than 150,000 Americans — the most ever — died from alcohol and drug-induced fatalities and suicide in 2017. That’s more than twice as many as in 1999, according to a new analysis released on Tuesday by our organizations, Well Being Trust and Trust for America’s Health.
To truly tackle complex, deeply rooted societal problems like these, we need to transform fragmented and disjointed community systems. Deaths from substance misuse and suicide are symptoms of broader problems. If we treat only the symptoms, more and more people will be at risk and die needlessly.
To address the underlying causes, we need a comprehensive approach that includes increasing funding and support for programs that reduce risk factors for despair and promote resilience in children, families, and communities. Exposure to trauma and adverse life experiences at young ages increases the potential for substance misuse and suicide. Programs that reduce community violence; address poverty and discrimination; create safe, supportive schools and quality learning experiences; and promote access to secure housing and employment opportunities can decrease adverse experiences and build resilience.
For example, the Nurse-Family Partnership works with young, low-income women who are pregnant for the first time. A public health nurse meets with the mother from pregnancy until the child turns 2, establishing a trusted relationship with both. The home visits connect first-time mothers with the care and support they need to ensure a healthy pregnancy and birth. The model has been shown to have dramatic benefits to society. For instance, when Medicaid pays for Nurse-Family Partnership services, the federal government gets a 54 percent return on its investment.
Along that line, the nation should expand substance misuse prevention and mental health programs in schools by increasing the number of schools that get training for, can screen for, and can respond to childhood trauma. Schools should also be supported in scaling up evidence-based life- and coping-skills programs like the Good Behavior Game, and increasing the availability of culturally appropriate mental health and other services.
Schools should also work with other community agencies to assist the families of the children who have experienced trauma. Successful school substance misuse prevention programs return $3.80 to $34 for every $1 invested; social-emotional learning programs provide an $11 for $1 return; and school violence prevention programs (including suicide) have a $15 to $81 return.
The nation will see results only if it addresses the need for a multigenerational response that includes substance use disorder treatment for parents and additional support for all caregivers while also expanding resources for the foster care system.
Model programs have been effective in helping mothers achieve sobriety, reducing state custody placement of children by half and producing a strong return on investment. Sobriety Treatment and Recovery Teams (START), for example, is a Kentucky-based program for families with parental substance use disorders and issues of child abuse and/or neglect. It helps parents achieve sobriety and, when possible, keeps children safely with their parents. Mothers who participated in START achieved sobriety at nearly twice the rate of those not in the program and children in START families were half as likely to be placed in state custody. For every dollar spent on START, Kentucky avoided spending $2.22 on foster care.

Doctors: CDC Guidelines Are Hurting Pain Patients

From the Washington Post, March 6, 2019:

Health-care providers say CDC’s opioid guidelines are harming pain patients

March 6, 2019 at 8:20 PM
More than 300 health-care experts told the Centers for Disease Control and Prevention Wednesday that the agency’s landmark guidelines for the use of opioids against chronic pain are harming patients who suffer from long-term pain and benefit from the prescription narcotics.
The health-care providers, including three former U.S. drug czars, said the CDC recommendation of a daily numerical threshold for opioid use has led insurers to refuse reimbursement, pharmacies to erect obstacles to obtaining drugs and risks for doctors who want to give out more.
“Taken in combination, these actions have led many health care providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care,” they said in a letter to the agency.
They said patients have endured unnecessary pain, turned to illegal drugs and even committed suicide.
The role of opioids for chronic pain has been one of the most contested aspects of the nationwide crackdown on narcotic prescribing. The CDC guidelines, issued in 2016, assert there is little evidence for the use of opioids against pain beyond 12 weeks.
But many patients have claimed that long-term use of the drugs is all that stands between them and unrelenting pain, and that they can take the medication without becoming dependent or addicted. The accumulation of that anecdotal evidence led to the experts, who call themselves Health Professionals for Patients in Pain, to write to the CDC.
The CDC did not respond to a request for comment Wednesday.
The National Institutes of Health is studying the issue as part of its Helping to End Addiction Long-term Initiative and last week the Food and Drug Administration ordered drug companies to examine whether opioids are effective against chronic pain.
In the meantime, the number of opioid prescriptions issued annually has fallen sharply, from a peak of more than 255 million in 2012 to 191 million in 2017, according to the CDC. Many states have enacted limits on opioid prescribing.
Still, 47,600 people died of opioid overdoses in 2017, more than 17,000 of them from legal painkillers such as oxycodone, hydrocodone and methadone.
The CDC guidelines suggest 90 milligrams of morphine or their equivalent as a daily ceiling for opioid use against pain. But the letter said insurers, regulators and others have used the figure “as both a professional standard and a threshold for professional suspicion.”
The group called on the CDC to investigate the damage that the limit may be doing to patients and to clarify the guidelines, especially in regard to discontinuing patients’ opioid use.

Wednesday, February 13, 2019

New USPTF Guidelines on Prevention of Perinatal Depression

The US Prevention Task Force has issued a new guideline for prevention of perinatal depression, and it's surprising how easy it is. A few sessions of CBT or interpersonal therapy, usually initiated in the second trimester, significantly reduced the incidence of perinatal depression. The Task Force went on to stated that it had moderate confidence that if this were widely implemented, it could provide a substantial public benefit. It's important the this was done preventively, before depression was established. It should be done in high risk groups: women with a history of depression, subsyndromal symptoms of depression, and women in certain groups. These include low socio-economic status, adolescent or single parenthood, recent partner violence, elevated levels of anxiety or a history of negative life events. Insufficient or mixed evidence was found for other potential interventions, including exercise, dietary supplements, pharmacotherapy, and health systems interventions. The group concluded that physicians should provide counseling or refer pregnant women in these high-risk groups for counseling.

Tuesday, January 22, 2019

Small Study Suggests That Naltrexone Blockade Dose Not Block Ketamine Response

A small study at Yale demonstrated that treatment with naltrexone, an opioid-blocking agent used to treat alcohol use disorder, does not interfere with an antidepressant response to ketamine. Yoon, et al. followed 5 subjects being treated with naltrexone as they received ketamine infusions for depression. Three of five subjects showed remission, and 5/5 showed response. (See figure for details.)

This study contradicts an earlier one that showed no ketamine response for people under naltrexone blockage. More to come, I'm sure.

Recent data on opioids from the CDC

Study Shows Urban-Rural Split on Opioid Prescribing Rates; Putting the Numbers to Fentanyl Deaths in NYC

A new study just released from the CDC confirmed findings that opioid prescriptions were nearly twice as likely to occur among rural residents, compared to central metro areas. (GarcĂ­a MC, Heilig CM, Lee SH, et al. Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System — United States, 2014–2017. MMWR Morb Mortal Wkly Rep 2019;68:25–30. DOI:  The study analyzed data from the AthenaHealth electronic medical record system. This cloud based EMR is used by about 100,000 providers serving 86 million patients. De-identified data were used for the study.

The first take-home message is that there is a lot of opioid prescriptions flying out of rural providers’ offices. At the last data point in 2017, about 9% of patients in non-core and micropolitan areas, whereas only 5% received a prescription in central metropolitan areas.

A second major finding was that the percentage of patients in metro areas remained remarkably stable, at 5%, whereas in rural areas, it got as high as 10.3%, before starting to drop since 2016. 

The authors correctly point out that there are many possible reasons for such a finding. However, the split between rural and urban areas is solid.

In another article from the same issue (Colon-Berezin C, Nolan ML, Blachman-Forshay J, Paone D. Overdose Deaths Involving Fentanyl and Fentanyl Analogs — New York City, 2000–2017. MMWR Morb Mortal Wkly Rep 2019;68:37–40. DOI:,) deaths from fentanyl overdose increased dramatically. In 2012, about 2% of deaths involved fentanyl, but by 2017, fentanyl involvement was present in 57% of overdose deaths in New York City.

The CDC's Morbidity and Mortality Weekly is available to all here

Friday, July 20, 2018

Good New About American Teens!


More U.S. Teens Shunning Drugs, Alcohol

By  Alan Mozes
HealthDay Reporter

THURSDAY, July 19, 2018 (HealthDay News) -- Over the last four decades, more American teenagers have decided to say no to drugs and alcohol, a new report shows.

"There has been a steady increase in the proportion of students graduating high school who report never having tried alcohol, marijuana, tobacco or any other drugs," said study author Dr. Sharon Levy. She directs the adolescent substance use and addiction program at Boston Children's Hospital.

For example, while about 5 percent of high school seniors had embraced abstinence in 1976, that figure had risen to 25 percent in 2014, according to the most recent poll of nearly 12,000 students.

Surveys conducted among 8th and 10th graders between 1991 and 2014 unearthed a similar trend, with abstinence jumping from roughly 10 percent to almost 40 percent among the former, and from 25 percent to more than 60 percent among the latter.

There was also a jump in total abstinence during the month leading up to each survey, rising from just over 20 percent among high school seniors in 1976 to more than 50 percent by 2014. Among 8th graders, that jump was from about 50 to about 65 percent, while among 10th graders month-long abstinence rose from about 65 to roughly 85 percent, the findings showed.

Levy said the downward trends didn't catch her off-guard, even if "the findings may surprise people because we constantly hear bad news about drug use and the opioid epidemic."

She explained that both drinking and smoking -- the number one and number three most common substance use habits -- have been sliding in popularity across the board for a while now, even though pot use has held steady.

But why? That remains "the million dollar question," said Levy, "and for sure it doesn't have one simple answer."

Overall, she credited public health efforts for giving rise to a new cultural climate that encourages teens to shun substance use because it's dangerous and unhealthy, rather than because it's immoral or forbidden.

Dr. Eric Sigel, an adolescent medicine specialist at Children's Hospital Colorado in Aurora, said the results of those efforts are "encouraging."

Sigel, who was not part of the study team, attributed the trend to successful grassroots campaigns such as Mothers Against Drunk Driving (MADD), the increased availability of mental health and substance use programs, better parental role-modeling and an emphasis on the harsh health risks posed, particularly by cigarettes.

Still, Levy warned that the good news "is quite precarious."

For example, "while fewer teens overall are using substances, those who do face a landscape of more dangerous substances [like opioids] compared to their parents' generation," Levy said.

Investigators also found that white and Hispanic teens were less likely to choose abstinence, compared with their black peers. And because girls are more likely than boys to "misuse" prescription drugs -- particularly pain medications -- they were also less likely to be fully abstinent, despite less frequent alcohol, marijuana and tobacco use.

"This is a good reminder that parents, primary care providers and other trusted adults should be talking to kids about avoiding prescription medications, knowing how addictive they can be," Levy said.

What's more, she stressed that "there are always lurking threats to our progress." In particular, Levy pointed to the soaring popularity of e-cigarettes and the steadfast appeal of marijuana, both of which are increasingly perceived as safe.

Those threats were also highlighted by Sigel.

"Society has not as yet focused those [education] efforts on marijuana being detrimental to youth," he said. "Nor have we had the opportunity to combat the whole vaping/electronic use of tobacco products."

Both habits are on the rise, Sigel said, a "foreboding" development that "could influence these [abstinence] trends for years to come."

The study findings were published online July 19 in the journal Pediatrics.

More information

There's more on substance use and teens at the U.S. National Institute on Drug Abuse.

SOURCES: Sharon Levy, M.D., MPH, director, adolescent substance use and addiction program, division of developmental medicine, Boston Children's Hospital; Eric Sigel, M.D., adolescent medicine specialist, Children's Hospital Colorado, Aurora; July 19, 2018, Pediatrics, online

Friday, June 15, 2018

Opening in Los Angeles!

Opening in California!

I’m pleased to announce the opening of Alltyr Addiction and Mental Health Services in Los Angeles, CA! In order to establish a footprint there, we’ve rented an office at 10886 Wilshire Blvd, Los Angeles, CA 90024. It’s on the corner of Wilshire and Westwood, near UCLA.

I’ll be coming out for the first time next week. I’ll be arriving Thursday night, and I’ll be in the office all day Friday and possibly Sat AM. Phone number is the same. I’ll be out monthly at first, and do the rest via telehealth. As business picks up, I’ll be coming out more often and/or for longer time periods.

I’m really looking forward to bringing Alltyr’s brand of 21st Century addiction and mental health treatment to California!