Collected Date: 2023 | Published Date: July 30, 2024 | Type: Annual Report
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This blog was also published in the American Society of Addiction Medicine (ASAM) Weekly on July 24, 2024.
Over the past several years, the increasing prevalence of fentanyl in the drug supply has created an unprecedented overdose death rate and other devastating consequences. People with an opioid use disorder (OUD) urgently need treatment not just to protect them from overdosing but also to help them achieve recovery, but highly effective medications like buprenorphine and methadone remain underused. Amid this crisis, it is critical that methadone, in particular, be made more accessible, as it may hold unique clinical advantages in the age of fentanyl.
Growing evidence suggests that methadone is as safe and effective as buprenorphine for patients who use fentanyl. In a 2020 naturalistic follow-up study, 53% of patients admitted to methadone treatment who tested positive for fentanyl at intake were still in treatment a year later, compared to 47% for patients who tested negative. Almost all (99%) of those retained in treatment achieved remission . An earlier study similarly found that 89% of patients who tested positive for fentanyl at methadone treatment intake and who remained in treatment at 6 months achieved abstinence .
Methadone may even be preferable for patients considered to be at high risk for leaving OUD treatment and overdosing on fentanyl. Comparative effectiveness evidence is emerging which shows that people with OUD in British Columbia given buprenorphine/naloxone when initiating treatment were 60% more likely to discontinue treatment than those who received methadone (1). More research is needed on optimal methadone dosing in patients with high opioid tolerance due to use of fentanyl, as well as on induction protocols for these patients. It is possible that escalation to a therapeutic dose may need to be more rapid.
It remains the case that only a fraction of people who could benefit from medication treatment for OUD (MOUD) receive it, due to a combination of structural and attitudinal barriers. A study using data from the National Survey on Drug Use and Health (NSDUH) from 2019—that is, pre-pandemic—found that only slightly more than a quarter (27.8%) of people who needed OUD treatment in the past year had received medication to treat their disorder. But a year into the pandemic, in 2021, the proportion had dropped to just 1 in 5 .
Efforts have been made to expand access to MOUD. For instance, in 2021, the U.S. Department of Health and Human Services (HHS) advanced the most comprehensive Overdose Prevention Strategy to date. Under this strategy, in 2023, HHS eliminated the X-waiver requirement for buprenorphine. But in the fentanyl era, expanded access to methadone too is essential, although there are even greater attitudinal and structural barriers to overcome with this medication. People in methadone treatment, who must regularly visit an opioid treatment program (OTP), face stigma from their community and from providers . People in rural areas may have difficulty accessing or sticking with methadone treatment if they live far from an OTP.
SAMHSA’s changes to 42 CFR Part 8 (“Medications for the Treatment of Opioid Use Disorder”) on January 30, 2024 were another positive step taken under the HHS Overdose Prevention Strategy. The new rule makes permanent the increased take-home doses of methadone established in March 2020 during the COVID pandemic, along with other provisions aimed to broaden access like the ability to initiate methadone treatment via telehealth. Studies show that telehealth is associated with increased likelihood of receiving MOUD and that take-home doses increase treatment retention.
Those changes that were implemented during the COVID pandemic have not been associated with adverse outcomes. An analysis of CDC overdose death data from January 2019 to August 2021 found that the percentage of overdose deaths involving methadone relative to all drug overdose deaths declined from 4.5% to 3.2% in that period. Expanded methadone access also was not associated with significant changes in urine drug test results, emergency department visits, or increases in overdose deaths involving methadone. An analysis of reports to poison control centers found a small increase in intentional methadone exposures in the year following the loosening of federal methadone regulations, but no significant increases in exposure severity, hospitalizations, or deaths .
Patients themselves reported significant benefits from increased take-home methadone and other COVID-19 protocols. Patients at one California OTP in a small qualitative study reported increased autonomy and treatment engagement . Patients at three rural OTPs in Oregon reported increased self-efficacy, strengthened recovery, and reduced interpersonal conflict .
The U.S. still restricts methadone prescribing and dispensing more than most other countries, but worries over methadone’s safety and concerns about diversion have made some physicians and policymakers hesitant about policy changes that would further lower the guardrails around this medication. Methadone treatment, whether for OUD or pain, is not without risks. Some studies have found elevated rates of overdose during the induction and stabilization phase of maintenance treatment, potentially due to starting at too high a dose, escalating too rapidly, or drug interactions .
Although greatly increased prescribing of methadone to treat pain two decades ago was associated with diversion and a rise in methadone overdoses, overdoses declined after 2006, along with methadone’s use as an analgesic, even as its use for OUD increased. Most methadone overdoses are associated with diversion and, less often, prescription for chronic pain; currently, 70 percent of methadone overdoses involve other opioids (like fentanyl) or benzodiazepines .
Recent trials of models of methadone dispensing in pharmacies and models of care based in other settings than OTPs have not supported concerns that making methadone more widely available will lead to harms like overdose. In two feasibility studies, stably maintained patients from OTPs in Baltimore, Maryland and Raleigh, North Carolina who received their methadone from a local pharmacy found this model to be highly satisfactory, with no positive urine screens, adverse events, or safety issues. An older pilot study in New Mexico found that prescribing methadone in a doctor’s office and dispensing in a community pharmacy, as well as methadone treatment delivered by social workers, produced better outcomes than standard care in an OTP for a sample of stably maintained female methadone patients.
Critics of expanded access to methadone outside OTPs sometimes argue that the medication should not be offered without accompanying behavioral treatment. Data suggest that counseling is not essential. In wait-list studies , methadone treatment was effective at reducing opioid use on its own, and patients stayed in treatment. However, counseling may have benefits or even be indispensable for some patients to help them improve their psychosocial functioning and reduce other drug use. How to personalize the intensity and the level of support needed is a question that requires further investigation.
Over the past two decades, the opioid crisis has accelerated the integration of addiction care in the U.S. with mainstream medicine. Yet methadone, the oldest and still one of the most effective medications in our OUD treatment toolkit, remains siloed. In the current era of powerful synthetic opioids like fentanyl dominating the statistics on drug addiction and overdose, it is time to make this effective medication more accessible to all who could benefit. The recent rules making permanent the COVID-19 provisions are an essential step in the right direction, but it will be critical to pursue other ways that methadone can safely be made more available to a wider range of patients with OUD. Although more research would be of value, the initial evidence suggests that providing methadone outside of OTPs is feasible, acceptable, and leads to good outcomes.
Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.
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Guest Essay
By Scott Gottlieb
Dr. Gottlieb is a former commissioner of the Food and Drug Administration and is a senior fellow at the American Enterprise Institute.
More than 80,000 Americans each year are dying from fentanyl as the opioid epidemic has morphed into a grimmer, more sinister threat. What began as a crisis fueled by the reckless prescribing of painkillers has now become a deadly illicit trade in counterfeit OxyContin or Vicodin pills containing fentanyl at wildly inconsistent dosages. Depending on the amount of fentanyl used, even a single pill can be lethal.
China remains the primary source of fentanyl entering the United States. Historically, this has been in the form of finished pills shipped to consumers through international mail and express consignment carriers. But increasingly, chemicals used to manufacture fentanyl — referred to as precursor chemicals — are being sent to cartels in Mexico, where they are formulated into pills and trafficked across the border. As China cracks down on its illicit manufacturing sites, more of this illegal commerce is shifting to the precursor chemicals, and production routed through Mexico.
We must put an end to the illegal trade and production of this dangerously powerful opioid through sensible and overdue policies we can start putting in place today.
This starts with tightly regulating all the precursor chemicals, many of which escape existing restrictions, or evade oversight through constant remodification. As a recent Reuters investigation found, when part of illegal trade, the chemicals arrive as powders that are shipped by air, and the quantities needed to make huge numbers of fentanyl pills can fit in a jar or even a baggie. Sent in these small volumes, the illicit shipments can be hard to spot at interdiction sites or to be recognized if customs agents inspect them. Criminals often ship the chemicals into the United States rather than directly to Mexico, since it is easier to hide them among the large volume of packages that America receives. The chemicals are smuggled into Mexico, where turning them into fentanyl at drug cartel labs is a simple exercise — then trafficked back into the United States.
Despite these challenges, we can do more to disrupt the illicit trade of these chemicals.
In recent years, countries have imposed new restrictions on the chemicals used to make fentanyl. But so far, the measures have mostly focused on how the chemicals are being used, rather than controlling their transit at every point. Under American pressure, China has tightened the screws on illicit fentanyl manufacturing within its borders, placing all forms of fentanyl on its controlled substances list in 2019, and subjecting these drugs to stricter oversight. But the Chinese government has paid far less scrutiny to the booming trade in precursor chemicals. The United States needs to again demand that China zero in on these chemicals as part of its broader crackdown on fentanyl.
At the same time, the United States working with like-minded countries can institute more stringent global regulations based on international drug control agreements. Such regulations must also target new “pre-precursor” chemicals (more basic formulations of existing chemicals) that cartels use to evade scrutiny.
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The number of babies born with severe birth defects affecting their growth and development is rising, as researchers now have strong evidence that illicit fentanyl is causing the problems.
Hospitals have identified at least 30 newborns with what has been identified as “fetal fentanyl syndrome,” NBC News has learned. The babies were born to mothers who said they’d used street drugs, particularly fentanyl, while pregnant.
“I have identified 20 patients,” said Dr. Miguel Del Campo, a medical geneticist at Rady Children’s Hospital in San Diego who specializes in children exposed to drugs and alcohol in utero. “I fear that this is not rare, and I fear kids are going unrecognized.”
The syndrome was first identified in 10 babies last fall by geneticists at Nemours Children’s Health in Wilmington, Delaware. The infants had specific physical birth defects: cleft palate, unusually small heads, drooping eyelids, webbed toes and joints that weren’t fully developed. Some had trouble feeding.
Published research about the babies caught Del Campo’s attention. He’d previously diagnosed some children with similar abnormalities with fetal alcohol syndrome, even though their mothers denied drinking while pregnant.
“After reading the paper and thinking about things,” he said, “I have recognized the potential for exposure to fentanyl.”
Dr. Karen Gripp, a geneticist at Nemours, and her team were the first to identify the 10 babies with fetal fentanyl syndrome last fall. “This is another huge piece of the puzzle” explaining the defects, she said.
The birth defects in the babies closely resemble a rare genetic condition called Smith-Lemli-Opitz . It’s a condition that affects how fetuses make cholesterol, which is critical for the brain to develop properly. But none of the babies had Smith-Lemli-Optiz.
The mothers’ reported drug use was a strong clue as to what was causing the defects, but there was no scientific evidence that fentanyl stopped cholesterol production in developing fetuses.
When Gripp and a team of researchers at the University of Nebraska Medical Center exposed human and mouse cells to fentanyl, they discovered that the drug directly disrupted their ability to make cholesterol.
“This is not something that people had known before, that fentanyl interferes so significantly with cholesterol metabolism,” Gripp said. “This is so important because cholesterol needs to be synthesized as the embryo develops.”
Their paper explaining the connection was published in Molecular Psychiatry in June.
Illicit fentanyl use during pregnancy is a known risk factor for preterm birth and stillbirth. Babies born after significant fentanyl exposure in utero may have seizures, vomiting, diarrhea and be irritable, fatigued and have trouble feeding.
But despite a rise in fentanyl misuse, even during pregnancy , there is no indication of a concurrent rise in birth defects. And most babies exposed to fentanyl in utero aren’t born with the defects that are hallmarks of the fetal fentanyl syndrome.
The new research helps to explain that.
While two copies of the gene that causes Smith-Lemli-Optiz result in the syndrome, cells with just one copy of that gene were more likely to be affected by fentanyl exposure.
That is, a single copy of the gene may make some babies more vulnerable.
“Not everyone is equally susceptible,” Dr. Karoly Mirnics, one of the study authors and director of the University of Nebraska Medical Center's Munroe-Meyer Institute, said in a press release announcing the results. “The potentially adverse effects of any medication or chemical compound might depend on your genes, lifestyle and environmental factors. One drug might not cause problems for me and might be catastrophic for you.”
Gripp expects the number of documented fetal fentanyl cases will rise with awareness and continued research.
“The group is growing,” she said. “We anticipate that there will be many more patients.”
Del Campo, also an associate professor at the University of California San Diego, said it’s critical to diagnose babies appropriately with fetal fentanyl syndrome so doctors can follow them long term.
“We need to know how these kids are doing. I have some 2 year-olds that are very concerning,” he said. “They’re just not growing or developing.”
Erika Edwards is a health and medical news writer and reporter for NBC News and "TODAY."
Works cited.
One of the consequences of using drugs is, eventually, an individual becoming addicted. Addiction refers to a neuropsychological disorder that involves persistently feeling an urge to engage in particular behaviors despite the significant harm or negative effects. The psychology that explains addiction covers many areas, such as an illness or personal problem, an effect of someone’s lifestyle, family history, or socioeconomic demographics. This paper aims to highlight what the field of psychology says about the negative effects of drugs and why people continue using despite the consequences.
Using drugs once does not necessarily mean someone will never consume them again. In most cases, the drugs contain elements that can cause a person to become addicted. From a psychological perspective, it is important to understand how people enter into addiction. At the root of addictive behavior is a level of emotional stress deeply hidden within someone’s subconscious mind, and addressing it becomes a challenge. To relieve stress, pleasure is discovered in excess (Bechara 100). An example is when people choose to drink alcohol to ease their pain and ultimately find fun.
Stopping the behavior is a danger to someone’s mental state as they fear returning thoughts of the initial source of emotional stress. When a person is addicted, it suggests they lack healthy coping methods for the problem. The only mechanisms are distracting as well as unhealthy such as substance usage. Individuals dealing with addiction do not care about what matters since what is important to them is the desire to do something when that stress appears (Bechara 101). Some can stop their behaviors as their emotional stress does not manifest as among the addictive behaviors. Meanwhile, for others, their drug usage indicates an issue they may not have known and needs treatment. This leads to associative learning, which refers to learning to do something according to a novel stimulus.
It is regarded as associative learning when an individual finds and takes drugs and ultimately gets high. The concept can be further explained using Ivan Pavlov’s experiment, where he rang a bell to call a dog and then rewarded it with food (Fouyssac and David 3015). A specific part of the brain controls associative learning, which it does via a neurotransmitter named dopamine. Dopamine is produced naturally by the brain when an individual does something rewarding or pleasurable.
The dopamine effect is a survival mechanism whereby eating or drinking feels good. It ensures continuity of life, family, and species in general. The element’s production is among the key drivers behind sex since, as much as the act is rewarding and pleasurable simultaneously, it is needed for survival (Fouyssac and David 3015). The main effect is that it creates a memory of the experience, which pushes people to seek the feeling again. People forget about the negative effects of drugs due to the moments of pleasure. As mentioned earlier, it is most likely that someone who uses the drug once will consume it again. The feeling established, regardless of how long, is enough to convince a person to forget everything they know concerning the negative effects and pursue a minute or two of a great time.
The paper has highlighted what the field of psychology says about the negative effects of drugs and why people continue using despite the consequences. It has been established that, in most cases, individuals experience addiction due to the pursuit of stress relief. Using the logic of the dopamine effect, once someone experiences something pleasurable or rewarding to them, they are most likely to pursue that feeling again. Eventually, it becomes impossible to convince them against the drugs as their desire to end their problem is more than the need to remain healthy.
Bechara, Antoine, et al. “A Neurobehavioral Approach to Addiction: Implications for the Opioid Epidemic and the Psychology of Addiction.” Psychological Science in the Public Interest, vol. 20, no. 2, 2019, p. 96–127.
Fouyssac, Maxime, and David Belin. “Beyond Drug‐Induced Alteration of Glutamate Homeostasis, Astrocytes May Contribute to Dopamine‐Dependent Intrastriatal Functional Shifts That Underlie the Development of Drug Addiction: A Working Hypothesis.” European Journal of Neuroscience, vol. 50, no. 6, 2019, p. 3014-3027.
IvyPanda. (2023, August 26). Drug Abuse and Its Negative Effects. https://ivypanda.com/essays/drug-abuse-and-its-negative-effects/
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Unodc: southasia.
Colombo, Sri Lanka/15 July 2024: In the face of escalating drug abuse challenges, the government of Sri Lanka, in collaboration with UNODC, has embarked on a transformative journey to combat the widespread impact of addiction, with support of Japan.
Drug use disorders, a pressing issue globally, have particularly strained Sri Lanka’s public health and security systems, affecting its youth and communities. Sri Lanka has witnessed a troubling rise in drug-related issues, with a 13% increase in arrests for drug offenses during the 2022 economic crisis, totaling 152,979 individuals. The infiltration of narcotic drugs like cannabis, heroin, cocaine, and prescription medications has significantly impacted adolescents and young adults, including school-aged children. Despite these alarming statistics, there has been a notable shortage of effective prevention and treatment programs, leading to high relapse rates due to the chronic, relapsing nature of drug use disorders.
Recognizing the urgency, UNODC has been at the forefront, driving efforts to enhance drug demand reduction strategies in the country with community-based prevention and treatment programs starting in 2023. This approach aims to ensure wider availability of services while moving away from long-term, involuntary residential treatment centers.
A cornerstone of this initiative has been the training of 280 national trainers, facilitators, coordinators, and practitioners on evidence-based prevention and treatment programs. Additionally, over 600 stakeholders, both national and international, have been educated on science-based, human-rights-oriented, and age- and gender-responsive approaches, aligning with the UNODC-WHO International Standards on Drug Use Prevention and Treatment.
Stakeholders from Colombo and neighbouring districts such as Ampara, Anuradhapura, Batticaloa, Badulla, Galle, Gampaha, Jaffna, Kalutara, Kandy, Kegalle, Kilinochchi, Kurunegala, Matara, Manner, Negombo, Trincomalee, Vavuniya have been engaged and trained.
In collaboration with the NDDCB and national/international consultants, UNODC is also assisting implementation of drug use survey using indirect estimation method in order to obtain updated burdens of drug use with attention to methamphetamine in 2024.
In partnership with the National Dangerous Drugs Control Board (NDDCB) and other consultants, UNODC is also facilitating a drug use survey using indirect estimation methods to update the understanding of drug use burdens in Sri Lanka, with a particular focus on methamphetamine. This comprehensive approach ensures that the strategies remain relevant and effective in addressing the evolving drug abuse landscape.
The collaborative efforts are laying the groundwork for a more resilient and informed approach to drug demand reduction in the future. Through these sustained efforts, Sri Lanka is making strides towards a healthier, safer future for its people, showcasing the power of international cooperation and evidence-based solutions in the fight against drug use.
The activity contributed to SDG3, SDG 16 and SDG 17: https://sdg-tracker.org/
(Supported by Government of Japan)
Copyright © 2024 UNODC, All Rights Reserved, Legal Notice
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The dopamine effect is a survival mechanism whereby eating or drinking feels good. It ensures continuity of life, family, and species in general. The element's production is among the key drivers behind sex since, as much as the act is rewarding and pleasurable simultaneously, it is needed for survival (Fouyssac and David 3015). The main ...
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Drug use disorders, a pressing issue globally, have particularly strained Sri Lanka's public health and security systems, affecting its youth and communities. Sri Lanka has witnessed a troubling rise in drug-related issues, with a 13% increase in arrests for drug offenses during the 2022 economic crisis, totaling 152,979 individuals.
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