Addiction Policy Forum Blog

7 min read

The role of alcohol, drugs, and despair in falling U.S. life expectancy

By Mark Gold, MD on January 16, 2020

After 2014, U.S. life expectancy fell for 3 straight years. This striking trend is not associated with other wealthy countries in the world and has given rise to a cottage industry of speculation on causes, with varied social, cultural, and political actors making use of the findings for preferred narratives. Some of this speculation arose after Princeton economists Anne Case and Angus Deaton coined the term “deaths of despair,” an easily misunderstood phrase. Case and Deaton used the term to refer to fatal drug overdoses, alcohol-related diseases, and suicides. “We think of all these deaths as suicides, by a very broad definition,” these economists have written,“and we attribute them to a broad deterioration in the lives of Americans without a college degree who entered adulthood after 1970.”

In late 2019, a National Institute on Aging-supported review offered a comprehensive examination of falling U.S. life expectancy. This study used data from the CDC, National Center for Health Statistics, and U.S. Mortality Database to trace life expectancy trends over a longer time frame and analyze mortality rates for particular age cohorts. It paints a complicated picture of poor U.S. mortality trends, which are not driven just by our polysubstance epidemics, and a decidedly unhappy one. The authors write, “According to one estimate, if the slow rate of increase in US life expectancy persists, it will take the United States more than a century to reach the average life expectancy that other high-income countries had achieved by 2016.”

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7 min read

Physician substance use disorders: contingency management encourages recovery?

By Mark Gold, MD on December 26, 2019

“Imagine if,” write the authors of a review in The New England Journal of Medicine, “the medical profession barred anyone being treated with pharmacotherapy for depression from returning to practice, insisting that only physicians who had achieved remission with cognitive behavioral therapy were fit to practice.” Why might readers imagine this? Physicians and nurses with opioid use disorder (OUD) are encouraged or required to participate in physician health programs, or PHPs, state-based treatment programs studied by experts like McLellan, Dupont, and Merlo, among others.1 These programs are often focused on abstinence and have defined 5-year outcomes, including fitness for duty and return to work. This New England Journal of Medicine article makes a case for lifting bans on medication-assisted treatment (MAT) in some PHPs and orienting the programs around structural health challenges faced by medical professionals. 

It is certainly true that PHPs have a history of successful recovery, return-to-work rates, and premorbid function outcomes for physicians who are monitored and active in such programs. But all physicians are not the same. Substance Use Disorders (SUDs) are not the same, either, and physician specialties have different risks.2 Before the public heard of fentanyl, for example, it was a dangerous substance for anesthesiologists.3 And health care professionals and business executives can become political footballs in the MAT vs non-MAT dichotomy. 

I like to frame this discussion around personalized medicine. We do not currently have tests or other predictors gauging which person with OUD will best recover at 5 years, and with which treatment. Some studies on PHPs suggest that health care professionals have the best 5-year return-to-work and premorbid function outcomes reported. This may be due to the generally late onset of SUDs in physicians. It could be that a given PHP works because of contingency management—follow the program and you can continue to be a physician. Contingency management is one of the most effective behavioral interventions for OUD and used much more frequently in PHPs than in non-PHP treatment settings. But few psychiatrists or addiction specialists understand the overall utility and efficacy.4 

We need more research to figure this out, but physician intervention, treatment, and recovery has been a model for successful 5-year outcomes and multidisciplinary treatment.5 Some programs are strictly oriented around a non-medication approach, but others are more flexible. Some programs have mandated MAT, like those requiring naltrexone for anesthesiologists6 returning to work, but others may prohibit MAT. Merlo has reported on outcomes and on MAT utilization in this population. She found that “individuals with opioid use disorders managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without opioid substitution therapy (OST ) through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.”7

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7 min read

The fentanyl crisis is only getting worse

By Mark Gold, MD on October 31, 2019

Synthetic opioids like fentanyl accounted for around 3,000 deaths in 2013—by 2018, they accounted for over 30,000.1 Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin. Breathing can stop after use of just two milligrams of fentanyl. That’s about as much as trace amounts of table salt. “Ten years ago,” write the authors of a recent RAND report on the future of fentanyl, “few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest.” Drug epidemics and outbreaks can be surprising, taking unexpected forms at unpredictable moments in uncharacteristic patterns. But the fentanyl crisis is different. It isn’t just distressingly surprising or one more deadly drug epidemic in a grueling, tragic history of new contagions. Its magnitude, intensity, and sharp variations dwarf previous epidemics with which experts and officials are familiar, and its challenges for public health are novel and, so far, unmanageable. The recent RAND report is a comprehensive overview of the fentanyl crisis’s origins, present status, and, most disturbingly, future.

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7 min read

What is TMS and can it help treat withdrawal, addiction, and patients with SUDs like it can treat depression and OCD?

By Mark Gold, MD on September 19, 2019

In April, The Atlantic published a piece about a young woman who became a viral internet sensation after she was photographed wearing a futuristic-looking hat or device on her head.1 Some online commentators dubbed the large, grey headwear, connected by a strap under the chin, “the depression helmet.” What the commentators did not understand is that such devices are part of a safe, effective, FDA-approved treatment for depression: transcranial magnetic stimulation, or TMS. At the University of Florida, in 2008, I was part of a team that purchased one of the first TMS machines sold after FDA approval. We bought other machines and did TMS research as well. Since that time, the technique has been used successfully to treat depression around the world. It was also approved in 2013 for the treatment of pain associated with certain migraine headaches, and more recently approved for the treatment of Obsessive-Compulsive Disease.2

At least 100 randomized clinical trials have been completed in an attempt to find a MAT which might treat cocaine use disorder, employing over 50 chemical compound medications. With very little progress made from early work3, none have been shown to be particularly useful4, until the current day and TMS. Treatment must reverse more than acute or even chronic dopamine neuron effects of cocaine. The TMS research group at the National Institute of Drug Abuse (NIDA) in Baltimore works on TMS research, dopamine plasticity, cocaine and SUD-related dopamine changes. TMS offers us a chance to intervene against cocaine and other substance’s ability to change the firing rates and key brain circuits that ultimately reduce dopamine release. The TMS research group is working to define how SUDs change the brain, intrinsic and synaptic plasticity control dopamine neurons, and what might be done to return the brain to pre-drug functionality.5

NIDA TMS researchers were featured in a cover story on the science of addiction in National Geographic.6 This article describes how a psychiatrist in Italy, who has treated addiction for 30 years,  became interested in TMS and began using it for treatment. It also details the successful use of traditional TMS treatment on a chronic relapsing patient, treated as if he had a naturally occurring depression. The psychiatrist, patient, and NIDA researchers are all interviewed for the story. TMS is not shock therapy; it delivers electromagnetic pulses to the brain in dopamine rich areas, resulting in painless, rapid magnetic pulses delivered through a pad or cap or hat. It is called non-invasive, and clearly has the ability to use  magnetic stimulation to drive the brain’s circuitry with electric currents. TMS can increase and decrease cortical excitability, through high and low frequency wave generation.  Scientists are very excited about this as TMS may help rebuild neural connections, or possibly regenerate dopamine systems damaged by substance use. The psychiatrist featured in the National Geographic article, Luigi Gallimberti, MD, has subsequently used TMS to treat other addictions. 

Medication assisted therapies are approved and used for detoxification, maintenance, and relapse prevention. Unfortunately, these do not address many of the changes produced by cocaine and other drugs. Even patients following these treatment plans and taking medications often feel a lack of energy, diminished pleasure, and declining enthusiasm, and drop out of treatment. TMS might not help people to stop using drugs, but it could be beneficial in helping with addiction and post-addiction related depression and anhedonia.7 TMS researchers have become part of a promising frontier for combating craving, addiction, relapse, and co-occurring depression. Greeting with laughter images of TMS devices, caps, and hats is a perfectly unhelpful reaction in the middle of a major opioid crisis.

FDA approval for treating depression through TMS piqued interest in applying the technique to substance use disorders, since depression is often a major part of SUDs, and a cause of relapses and overdoses, as a recent consensus review on the current state of non-invasive brain stimulation science pointed out. Neuroscience research has helped establish connections between substance-using behavior and particular neural circuits, which prompted additional interest in using TMS and related techniques to treat substance use disorders. TMS is no longer an experiment. With time, SUD researchers have compiled more studies on non-invasive brain stimulation, symptoms, and outcomes, leading to new reviews on relative effectiveness and future development prospects.


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2 min read

Ask a Counselor: Yes, Mixing Substances is Dangerous and Potentially Lethal

By Addiction Resource Center on July 24, 2019

It is important to understand how substances, including prescribed medications, can interact with each other and other substances. Mixing medications-- whether the medication is prescribed by a doctor, available over-the-counter, or otherwise-- can be dangerous both in the long and the short-term. Make sure to consult with your prescribing doctor when you have any questions about what medications you are taking and how they may interact with other substances you may be using. It is also important to know what your medications are being prescribed to treat, and to be honest when your doctor ask what medications or supplements you are taking so they can better understand what may interact negatively with each other.

It is important to note that mixing 2 or more substances significantly increases the risk of dangerous or fatal effects. For example, a study done in Florida found that over 90% of opioid overdose deaths in the state included other, non-opioid drugs with an average of 2–3 drugs other than the opioids found at autopsy. (1)

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3 min read

Data sharing among ED physicians could reduce drug overdose

By Mark Gold, MD on June 27, 2019

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