Pharmacies and OD reduction: Part of the problem, or the solution? - MindSite News (2024)

Tuesday, May 28, 2024

By Don Sapatkin

Good post-Memorial Day Tuesday morning! In today’s Daily: In the fight to reduce overdose deaths, pharmacies can be part of the solution. Instead, some experts say, many are part of the problem. More people are now using marijuana on a near-daily basis than alcohol – even though drinking-related deaths are rising fast.

Plus: Doctors are still figuring out attention-deficit disorders. Mental illness may be (socially) transmissible. Members of racial and ethnic minority groups with fair or poor mental health are less likely to get treatment than whites. And scientists draw complex brain maps that may point to risks for mental disorders. (I don’t understand it either, but the findings are said to be notable.)

Pharmacies and overdose deaths: Part of the problem, or part of the solution?

To make a real dent in the overdose crisis, many experts say, the medications that can help people stay off opioids need to be far more widely available. In recent years, policymakers have slowly – some would say glacially – made changes to accommodate that.

More doctors can now prescribe buprenorphine, the leading opioid addiction treatment. Naloxone, a medication that can reverse overdoses, is now available over the counter. But these medicines are only truly available if people can get them at a neighborhood pharmacy – and according to a commentary in the Forefront section of Health Affairs, they often are not.

An 11-state survey conducted in 2021 and 2022 found that naloxone availability in pharmacies varied widely among states, from 46% of stores in South Dakota to 88% in Massachusetts. And the federal Substance Abuse and Mental Health Services Administration says the number of pharmacies willing and able to fill a buprenorphine prescription also ranges widely from 42% to 73%, with less availability in areas that are rural or have large numbers of uninsured people or in southern states and those that didn’t expand Medicaid. The result: While the number of opioid-related overdose deaths was growing by 65 percent from 2019 to 2022, national buprenorphine dispensing rates barely budged.

Author Katharine Neill Harris, a drug policy fellow at Rice University, recommends that policy makers change rules and practices that are impeding widespread availability. For example, even though buprenorphine is a Schedule III drug considered to have less risk for misuse and addiction than Schedule II drugs like hydrocodone and oxycodone, the Drug Enforcement Administration requires pharmacies to document that they are taking steps to prevent it from being diverted (and sold on the black market). That makes pharmacists more cautious and risk-averse – and less likely to stock or dispense buprenorphine.

Similarly, the multi-billion-dollar settlements of lawsuits against major drug distribution companies and pharmacy chains require strict monitoring and blocking orders but make no exceptions for naloxone or buprenorphine. And using their broad, legitimate authority to decline prescription requests that seem suspicious, pharmacists also deny addiction treatment drugs to people who need them.

Harris argues that policymakers should remove barriers and encourage pharmacies to provide care. The DEA and state legislatures must clarify that prescribing buprenorphine to treat opioid use disorder is completely different from prescribing opioids to manage pain, she writes, and shouldn’t be subject to red flag laws. State Medicaid programs must expand coverage and reimbursem*nt for multiple formulations of buprenorphine and naloxone. And states should ban insurers from requiring prior authorization to cover medication-assisted treatments for opioid addiction.

More people use marijuana daily than alcohol – but drinking is still more common, and dangerous

More Americans now use marijuana on a near-daily basis than alcohol, the Associated Press reported, and not by a little: An estimated 17.7 million people said they used pot nearly every day in 2022 vs. 14.7 million who reported drinking alcohol almost daily.

That’s according to an analysis of data from the National Survey on Drug Use and Health published in the journal Addiction. Marijuana use has been increasing for 40 years, with the per capita rate up 15-fold since 1992. Public policy has followed. Medical marijuana is now legal in 38 states, recreational use in 24, and the Biden administration recently proposed rescheduling the drug to a less restrictive category. Pot is now close to mainstream.

Still, far more Americans drink – even if they don’t imbibe every day. People tend to use marijuana more like they do tobacco, with the median user consuming marijuana on 15 to 16 days in the previous month, while the median drinker reported alcohol use on four to five days in a month. Alcohol is far more dangerous, although there is relatively little data on deaths from marijuana. So while the DEA says no marijuana-related overdoses have been reported, an analysis published last year found that 386 marijuana-related deaths occurred in Florida from 2014 to 2020, most from auto accidents. Alcohol, by contrast, was directly responsible for 51,000 deaths and a contributing factor in another 54,000 – and thus was involved in 105,000 deaths in the U.S. in 2022, according to an analysis by the Kaiser Family Foundation. That’s 20% higher than the number of opioid-related deaths that year.

The number of alcohol-related deaths has increased sharply in the past decade, with a spike during the pandemic that has since eased slightly. Deaths increased the most among people ages 26 to 44, but were highest among those ages 45 to 64. The death rate among males was 40% higher than females in 2022, and it was 25% higher in rural areas than metro areas. Both death rates and changes over time varied hugely from state to state. By far the biggest disparity involved race and ethnicity, specifically for American Indian and Alaska Native people, whose death rate (78.4 per 100,000 people) was more than five times that of whites (14.8), with an even greater gap compared with Hispanics (13.2), Blacks (9.7), and Asian or Pacific Islanders people (3 per 100,000). Among the reasons that KFF noted for the overall rise in alcohol deaths were very low treatment rates for alcohol use disorder (7.6% in 2022, far lower than for opioid addiction) and the public’s lack of recognition that it’s a serious problem.

What doctors still don’t know about adult ADHD

Judy Sandler was diagnosed with ADHD in her mid-50s, after retiring from her job as a teacher. It was the first time in her life that she felt like she couldn’t get anything done. When she tried to write, she immediately had the urge to get up and do something else: “I’ll just do the laundry,” she would think. “And then go walk the dog.” I know the feeling well. It’s why I’m still writing this newsletter at 4 in the morning. Sandler, who is 62 and lives in Maine, did not recall having significant symptoms in school or at home – she’d benefited from a highly structured schedule – but they became problematic later in life. I’ve been easily distracted for years but I, too, kept very busy. My symptoms worsened considerably as I aged into (semi-)retirement.

Attention deficit hyperactivity disorder is typically diagnosed and is more common in children. It’s also one of the most common psychiatric disorders in adults. Yet many doctors have uneven training on how to evaluate it, and there are no U.S. clinical practice guidelines for diagnosing and treating patients beyond childhood. The American Psychiatric Association’s official manual of mental disorders contains a somewhat arbitrary requirement for ADHD: significant symptoms, such as continual forgetfulness and talking out of turn, should be present in at least two settings before age 12. Older patients may not recall childhood symptoms (I don’t, and I believe my recollection is correct) or say they were mild. The diagnostic manual, known as the DSM, does not officially mention problems with executive function, planning, organization and self-regulation, which are among the most frequent symptoms experienced by adults.

Without clear rules, some providers, while well-intentioned, are just “making it up as they go along,” David W. Goodman, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, told the New York Times. “There’s a lot more subtlety in making this diagnosis − especially in high-functioning, bright people − than just a symptom checklist,” he said.

Properly diagnosing ADHD in adults typically requires several steps, experts say: an interview with the patient, a medical and developmental history, symptom questionnaires and, if possible, conversations with other people in the patient’s life, like a spouse. Even then, it can be tricky. And there are chicken-and egg-questions: Research suggests that heavy users of digital technology are more likely to report ADHD symptoms. But did the symptoms develop because of the technology use or are people with ADHD more drawn to digital technology than the average person?

Goodman and other ADHD specialists from around the world, in collaboration with the American Professional Society of ADHD and Related Disorders, are developing what I was surprised to learn are the first U.S. guidelines for diagnosing and treating adults with the disorder. As recently as two decades ago, most mental health providers “didn’t really believe in adult ADHD,” Goodman said.

In other news…

Adolescents might “transmit” depression and anxiety to each other, according to a Medscape report on findings of a large study that suggest teens with classmates who have a mental illness are at greater risk for a psychiatric diagnosis later in life. The study, in JAMA Psychiatry, followed all 700,000 citizens of Finland born between 1985 and 1997 for up to 18 years. Researchers found a dose-response relationship, with the risk of social transmission increasing with each additional child with a mental disorder in the ninth grader’s peer network. Of the mental disorders examined, the risk was greatest for mood, anxiety, and eating disorders.

Although the study did not attempt to determine the reasons for social transmission, the authors mentioned several possible mechanisms: Having mentally ill classmates could lead to the “normalization of mental disorders” through increased awareness and receptivity to diagnosis and treatment, while having no one diagnosed with a mental illness in the social network might discourage members from seeking help for any underlying mental health problems. For certain categories, such as eating disorders, transmission could occur via social influence from peers, to which adolescents are particularly susceptible. For other disorders, like depression, “direct interpersonal contagion”could result from long-term exposure to a depressed individual, which might lead to “gradual development of depressive symptoms.”

Black and Latino adults who say they have fair or poor mental health are less likely to have received mental health services in the past three years (39% and 36%, respectively) compared to whites (50%), according to a Kaiser Family Foundation analysis of its 2023 Survey of Racism, Discrimination and Health. Barriers to care identified by participants overall include cost concerns and being too busy or not able to get time off from work. Latino and Black adults also disproportionately report other challenges such as being afraid or embarrassed to seek care, not knowing how to find a provider, or believing they would be unable to find one with a shared background. The analysis also found that awareness of the 988 national mental health hotline last summer, a year after it launched, was lower among racial and ethnic minorities than whites.

The largest and most advanced multidimensional maps of gene regulation networks in the brains of people with and without mental disorders were published in 15 papers in Science, Science Advances, and Scientific Reports, according to a press release from the National Institutes of Health, which supported the groundbreaking work. The consortium of researchers used postmortem human brain tissue from more than 2,500 donors to map gene regulation networks across different stages of brain development and multiple brain-related disorders, advancing scientific understanding of how, where and when genetic risk contributes to mental disorders such as schizophrenia, PTSD and depression. That, in turn, could eventually identify potential molecular targets for new therapeutics.

An unrelated mouse study in Nature reported that the addictive effects of fentanyl, which was involved in 70% of all U.S. drug deaths last year, could be controlled by two distinct neural pathways in the brain, according to a release from Springer Nature. The findings may help develop future treatments to reduce addiction.

If you or someone you know is in crisis or experiencing suicidal thoughts, call or text 988 to reach the988Suicide & Crisis Lifelineand connect inEnglish or Spanish. If you’re a veteran press 1. If you’re deaf or hard of hearing dial 711, then 988.Services are free and available 24/7.

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