This essay describes how a basic scientist was thrust into the epicenter, the political cauldron of our national drug control policy, and how the experience altered her professional trajectory and perspective.

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Office of National Drug Control Policy: a scientist in drug policy in Washington, DC.

RESULTS Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).

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Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial

BACKGROUND
Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.

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Health Care Contacts in the Year Before Suicide Death

anillegaldrugorusedaprescriptionmedicationfornonmedical reasons?” A response of at least 1 time was considered positive for drug use. They were also asked the 10-item Drug Abuse Screening Test (DAST-10). The reference standard was the presence or absence of current (past year) drug use or a drug use disorder (abuse or dependence) as determined by a standardized diagnostic interview.Drugusewasalsodeterminedbyoralfluidtesting for common drugs of abuse. Results:Of394eligibleprimarycarepatients,286(73%) completedtheinterview.Thesinglescreeningquestionwas 100%sensitive(95%confidenceinterval[CI],90.6%-100%) and 73.5% specific (95% CI, 67.7%-78.6%) for the detection of a drug use disorder. It was less sensitive for the detection of self-reported current drug use (92.9%; 95% CI, 86.1%-96.5%) and drug use detected by oral fluid testing orself-report(81.8%;95%CI,72.5%-88.5%).TestcharacteristicsweresimilartothoseoftheDAST-10andwereaffectedverylittlebyparticipantdemographiccharacteristics. Conclusion: The single screening question accurately identified drug use in this sample of primary care patients, supporting the usefulness of this brief screen in primary care. Arch Intern Med. 2010;170(13):1155-1160

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/225770/ioi05041_1155_1160.pdf

A single-question screening test for drug use in primary care.

Importance The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. Objective To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention. Design, Setting, and Participants This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. Interventions Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. Main Outcomes and Measures Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. Results At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P  = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. Conclusions and Relevance Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. Trial Registration clinicaltrials.gov Identifier:NCT00876941

https://jamanetwork.com/journals/jama/articlepdf/1892250/joi140093.pdf

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.

Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later

Back to table of contents Previous article Next article Letters to the EditorFull AccessIntentional Drug Overdose Deaths in the United StatesBeth Han, M.D., Ph.D., M.P.H., Wilson M. Compton, M.D., M.P.E., Emily B. Einstein, Ph.D., Jessica Cotto, M.P.H., Jennifer A. Hobin, Ph.D., Jack B. Stein, M.S.W., Ph.D., Nora D. Volkow, M.D.Beth HanSearch for more papers by this author, M.D., Ph.D., M.P.H., Wilson M. ComptonSearch for more papers by this author, M.D., M.P.E., Emily B. EinsteinSearch for more papers by this author, Ph.D., Jessica CottoSearch for more papers by this author, M.P.H., Jennifer A. HobinSearch for more papers by this author, Ph.D., Jack B. SteinSearch for more papers by this author, M.S.W., Ph.D., Nora D. VolkowSearch for more papers by this author, M.D.Published Online:2 Feb 2022https://doi.org/10.1176/appi.ajp.2021.21060604AboutSectionsView articleSupplemental MaterialPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleDuring 1999–2019, age-adjusted rates of U.S. drug-involved overdose deaths more than tripled from 6.1 to 21.6 per 100,000 (1), and suicide rates (driven primarily by firearm suicide) increased 35.2% from 10.5 to 13.9 per 100,000 (2). However, no existing studies examined differences in trends in intentional overdose deaths by age, race/ethnicity, and sex, compared with firearm deaths by suicide (2–4). Furthermore, variations of intentional overdose deaths by month and day of the week are unknown. Nevertheless, knowing these can help inform prevention and intervention efforts. Thus, we examined 1) What are differences in national trends in intentional overdose deaths by age, race/ethnicity, and sex, compared with firearm deaths by suicide? and 2) What are variations of U.S. intentional overdose deaths by month and day of the week and by sex?MethodData were analyzed using the 2001–2019 National Vital Statistics System’s multiple cause-of-death mortality files. Intentional drug overdose deaths were those assigned an underlying cause of death with ICD-10, X60–X64; firearm deaths by suicide were X72–X74. Age-adjusted intentional overdose death rates were stratified by age, race/ethnicity, and sex. Joinpoint Regression Program (version 4.8.01) was used to test for significant changes in nonlinear trends using permutation tests.To compare intentional overdose deaths by month, this study accounted for variations in the number of days by month and year (e.g., 29 days in February in a leap year) by examining adjusted mean number of intentional overdose deaths as the mean number of overdose deaths per day for a given month during 2001–2019 times 30 days. Death data were merged with average U.S. daylength by month and year. Mean numbers of intentional overdose deaths during 2001–2019 by day of the week were also assessed. Using SAS 9.4, Poisson regressions were applied in these analyses. A two-sided p value <0.05 was considered statistically significant.ResultsAlthough age-adjusted rates of intentional overdose deaths declined from 2012 to 2019 among men and from 2015 to 2019 among women (each p<0.001; see Table 1 in online supplement), rates trended upward among 15–24-year-old men from 2015 to 2019 (p=0.012), 15–24-year-old women from 2014 to 2019 (p<0.001), non-Hispanic Black women from 2013–2019 (p=0.015), and 75–84-year-old men and women from 2001 to 2019 (both p<0.001). Across groups by age and sex, rates were consistently highest among women aged 45–64 during 2001–2019 and were 41% higher than among men aged 45–64 in 2019 (p≤0.001).By contrast, age-adjusted rates for suicides by firearm increased among men and women from 2006 to 2019 (each p<0.001; see Table 2 in online supplement), and rates did not trend downward in any subgroups in recent years. In 2019, rates were over 10 times higher than by intentional overdose for men overall and most subgroups but were only slightly higher than by intentional overdose among women overall (1.2 times higher), non-Hispanic white women, and women aged 15–44 (each p<0.001).Adjusted mean number of intentional overdose deaths was higher in April-through-August for women and in March-through-August and January for men and was lowest in December for both sexes (p<0.05) (see Table 3 in online supplement). Long daylengths are in May-through-August, intermediate daylengths are in March-April and September-October, and short daylengths are in November-through-February (part a of Figure 1). We found intentional overdose deaths had a positive linear relationship with daylength for both sexes (incident risk ratio=1.020; p<0.001) (part b of Figure 1). For both sexes, intentional overdose deaths were lowest on Saturdays (similar to Sundays for men and Fridays for women) (p<0.05) (supplemental table 3 and part c of Figure 1) and highest on Mondays (p<0.05).FIGURE 1. Intentional overdose deaths as a function of day and daylengthData files: the 2001–2019 Multiple Cause-of-Death data from the National Vital Statistics System. The mean number of intentional drug overdose deaths on Saturdays was lower than Mondays through Thursdays for both sexes, was also lower than Fridays for men, and was lower than Sundays for women as well (p<0.05). It was higher on Mondays than all other days of the week for both sexes (p<0.05). See Table 3 in the online supplement for details.DiscussionWe observed recent upward trends in intentional overdose deaths in 15–24-year-olds for both sexes, which stand in contrast to recent downward trends for the overall male and female populations. These findings are consistent with increases in suicidal ideation, plan, and attempt in young people (5, 6) and highlight the urgent need for interventions to prevent suicides, including from intentional overdoses.Researchers have reported that suicide behavior with opioid consumption follows a seasonal pattern that changes with latitude (7). Our study found a positive linear relationship between daylength, which varies by latitude, and intentional overdose deaths for both sexes. Interestingly, a brain-imaging study reported that daylength was associated with mu opioid receptor (MOR) availability that might underlie seasonal variations in mood and social behaviors (8). Another study showing altered MOR expression in postmortem brains of decedents by suicide further supports their relevance (9). MORs are the main targets of opioid drugs, which are the most frequent substances identified in intentional overdose deaths (3, 10). Taken together, these findings may help explain the peak intentional overdose deaths in Spring-through-Summer (encompassing long daylengths in May-through-August) that we observed for both sexes. Our results are also consistent with other findings of increased suicide behavior in the Spring and Summer months (11).Importantly, social and cultural factors are likely to contribute to the lower intentional overdose deaths observed in December, which was also the month with the lowest suicide rate reported by an Austrian study (12). Social interactions and collective optimism during the holiday season might exert protective effects against suicidality.Similarly, the lower intentional drug overdose deaths on Saturdays, could reflect protective effects of social interactions. Higher intentional overdoses on Mondays was also reported for intentional overdose deaths from England and Wales (13) and for suicides in England (14), suggesting effects attributed to beginning the routine transition from the weekend to the work week.This study has limitations. Classifications of intentionality of drug overdose deaths may be inaccurate, and intentional overdose deaths may be underreported due to individual/system-level factors (15). In 2019, 5% of overdose deaths had undetermined intent (1), which may affect patterns of intentional overdose deaths. Improving classifications of overdose deaths is needed. These trends might have also changed during the COVID-19 pandemic as provisional mortality data indicate decreases in deaths from suicides (16), yet an approximately 30% increase in overall overdose deaths (17). Thus, further evaluations are needed.ConclusionsAlthough intentional overdose death rates decreased during 2012–2019 in men and 2015–2019 in women, we identified recent upward trends among 15–24-year-olds (both sexes), 75–84-year-olds (both sexes), and non-Hispanic Black women. Our findings indicate consistently higher rates of intentional overdose deaths among women (highest among 45–64-year-olds) than men. Preventive interventions are especially needed to target these groups. We also observed peak intentional overdose deaths in Spring-through-Summer and on Mondays and lower rates in December and on Saturdays for both sexes. These monthly patterns and day of the week variabilities for intentional overdose deaths may be driven by socially established routines, daylength, and overlapping factors, which may inform related prevention and intervention efforts.National Institute on Drug Abuse, National Institutes of Health, Bethesda, Md.Send correspondence to Dr. Volkow ([email protected]).Dr. Compton reports ownership of stock in General Electric Co., 3M Co., and Pfizer Inc. The other authors report no financial relationships with commercial interests.Sponsored by the National Institute on Drug Abuse of the National Institutes of Health. The sponsor supported the authors who were responsible for preparation, review, and approval of the manuscript and the decision to submit the manuscript for publication. The sponsor had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The sponsor reviewed and approved the manuscript.The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the National Institute on Drug Abuse of the National Institutes of Health and the U.S. Department of Health and Human Services.References1 Hedegaard H, Miniño AM, Warner M: Drug overdose deaths in the United States, 1999–2019. NCHS Data Brief, no 394. Hyattsville, MD, National Center for Health Statistics, 2020Google Scholar2 Hedegaard H, Curtin SC, Warner M: Suicide Mortality in the United States, 1999-2019. NCHS Data Brief, no 398. Hyattsville, MD, National Center for Health Statistics, 2021Crossref, Google Scholar3 Hempstead K, Phillips J: Divergence in recent trends in deaths from intentional and unintentional poisoning. Health Aff (Millwood) 2019; 38:29–35Crossref, Medline, Google Scholar4 VanHouten JP, Rudd RA, Ballesteros MF, et al.: Drug overdose deaths among women aged 30-64 years-United States, 1999-2017. MMWR Morb Mortal Wkly Rep 2019; 68:1–5Crossref, Medline, Google Scholar5 Han B, Compton WM, Einstein EB, et al.: Associations of suicidality trends with cannabis use as a function of sex and depression status. JAMA Netw Open 2021; 4:e2113025Crossref, Medline, Google Scholar6 Han B: Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2020Google Scholar7 Davis JM, Searles VB, Severtson SG, et al.: Seasonal variation in suicidal behavior with prescription opioid medication. J Affect Disord 2014; 158:30–36Crossref, Medline, Google Scholar8 Sun L, Tang J, Liljenbäck H, et al.: Seasonal variation in the brain μ-opioid receptor availability. J Neurosci 2021; 41:1265–1273Crossref, Medline, Google Scholar9 Lutz PE, Almeida D, Filliol D, et al.: Increased functional coupling of the mu opioid receptor in the anterior insula of depressed individuals. Neuropsychopharmacology 2021; 46:920–927Crossref, Medline, Google Scholar10 Miller TR, Swedler DI, Lawrence BA, et al.: Incidence and lethality of suicidal overdoses by drug class. JAMA Netw Open 2020; 3:e200607Crossref, Medline, Google Scholar11 Woo JM, Okusaga O, Postolache TT: Seasonality of suicidal behavior. Int J Environ Res Public Health 2012; 9:531–547Crossref, Medline, Google Scholar12 Plöderl M, Fartacek C, Kunrath S, et al.: Nothing like Christmas--suicides during Christmas and other holidays in Austria. Eur J Public Health 2015; 25:410–413Crossref, Medline, Google Scholar13 Johnson H, Brock A, Griffiths C, et al.: Mortality from suicide and drug-related poisoning by day of the week in England and Wales, 1993-2002. Health Stat Q 2005; 27:13–16Google Scholar14 Cavanagh B, Ibrahim S, Roscoe A, et al.: The timing of general population and patient suicide in England, 1997-2012. J Affect Disord 2016; 197:175–181Crossref, Medline, Google Scholar15 Stone DM, Holland KM, Bartholow B, et al.: Deciphering suicide and other manners of death associated with drug intoxication: A Centers for Disease Control and Prevention consultation meeting summary. Am J Public Health 2017; 107:1233–1239Crossref, Medline, Google Scholar16 Ahmad FB, Anderson RN: The leading causes of death in the US for 2020. JAMA 2021; 325:1829–1830Crossref, Medline, Google Scholar17 Centers for Disease Control and Prevention: Provisional Drug Overdose Death Counts. 12 month-ending provisional number of drug overdose deaths by drug or drug class. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed June 3, 2021.Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 179Issue 2 February 2022Pages 163-165 Metrics KeywordsSuicide and Self-HarmGender DifferencesEpidemiologyPDF download History Published online 2 February 2022 Published in print 1 February 2022 

Jack B. Stein

Papers

Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later

Intentional Drug Overdose Deaths in the United States.