The Fentanyl "State of Emergency" - Implications for the C/L Psychiatrist

Abstract:
The United States has the world’s highest rate of opioid-related deaths. Since 1999, more than 1 million people have died from drug overdoses in the United States, with an increasing share of those deaths occurring from opioids. Drug overdoses were the leading cause of mortality in the United States in 2022, surpassing motor vehicle accidents and gun violence. In 2023, over 112,000 deaths were attributed to fentanyl overdose. Fentanyl is now the leading cause of rising death rates for American adults under 49. The overdose epidemic grew rapidly during times of economic insecurity and the COVID-19 pandemic, leading to social isolation and barriers for accessing in-person substance use disorder treatment. In addition to devastating losses of life in families and communities and lost productivity from premature deaths, the overdose crisis is responsible for an estimated $1 trillion in annual costs to the U.S. health care and criminal justice systems. The current opioid epidemic presents a complex and multifaceted challenge that cannot be tackled by a single nor narrow approach. Consultation psychiatrists who care for patients with medical, psychiatric, and substance use co-morbidities in collaborative care, emergency and inpatient settings will be called upon to help manage complex substance use disorders. This session will address this crisis from different points of view and emphasize the relevance to the consultation psychiatrist.

Dr. Anne Gross, CMO of a psychiatric hospital, will begin with a discussion of the legal, social, and public health impacts of the fentanyl crisis and the challenges faced by government, public health, hospitals, and practitioners in addressing the crisis. She will discuss the history of the opioid crisis, the experience in Oregon with decriminalization and subsequent re-criminalization of possession of illicit drugs and the gaps in available treatment.

Dr. Marian Fireman, an experienced addiction psychiatrist, will discuss the unique pharmacology of fentanyl and the challenges of treating fentanyl intoxication and withdrawal. She will include a discussion of misused fentanyl analogs.

Dr. Shamim Nejad, Medical Director, Addiction Services, Valley Medical Center, Renton, Washington, will present complex cases highlighting different clinical presentations. A discussion of the pharmacology of naloxone, naltrexone, buprenorphine, and methadone will be included. He will discuss the current best practices in transitioning fentanyl patients to MOUD therapies while highlighting challenges in complex patients with co-occurring substance use disorders.

Dr. Allison Hadley, Psychiatric Emergency Service Medical Director, will discuss the development of an emergency substance use disorder center in Oregon, highlighting a case illustrating the patient’s journey through the center and the relevant factors considered in the development of the center including social determinants of health, harm reduction, trauma-informed care, and use of peer supports. She will discuss the importance of addressing the whole person in treatment including mental health issues, housing, social supports, and skill building. The challenges of implementing this service and the importance of collaboration with law enforcement, first responders and community services will be discussed.

The session will utilize cases and an audience response system to enhance interaction and will allow time for discussion and questions.