Monday January 29, 2024

By Don Sapatkin

Plus, fear is stopping some drug users from trying the leading opioid-addiction medication. And researchers find higher levels of anxiety in states that banned abortion after the Supreme Court overturned Roe v. Wade.

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A survey of crisis counselors reveals worries about training and pay. We interviewed the author

In the summer of 2022, the 200 or so crisis lines across the country were knitted together into a national network – the 988 Suicide & Crisis Lifeline. It has been successful in many ways: The easy-to-remember three-digit number has received more than 8 million calls, texts, and chats. Federal officials say shorter wait times and the ability to assist with a broad range of mental health crises is helping more people. But no one asked the crisis counselors who field the calls what they think.

Fichter decided he would. He conducted a survey of crisis counselors working at about 10% of the call centers. And it turns out they have lots of ideas for improvement. Some of the 47 respondents got just four days of training; others received two weeks. Some said they were trained only in how to help people having suicidal thoughts – even though many callers are experiencing anxiety attacks, mood disorders, intoxication and drug withdrawal.

Some of the counselors surveyed said they were expected to end conversations within 15 minutes with callers and texters who didn’t have immediate plans for suicide. “That’s certainly not in the spirit of what 988 stands for because there is no exact time that’s perfect to address a crisis,” Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness, told KFF Health News, in a story republished by MindSite News.

As a volunteer, Fichter got to see the power a compassionate, unrushed listener can bring. As soon as he got to know the caller in crisis, a path generally became clear, sometimes just by talking until their mood shifted. Most already had good ideas but needed someone to listen. “It’s an incredible front-row seat to someone’s resilience,” he said.

Fichter wants to empower hotline workers and improve call center practices. He told me in a MindSite News interview that crisis counselors feel intense pressure and responsibility as they make judgment calls that could mean life or death for suicidal callers. Yet many also feel like entry-level workers with no voice. Through the survey, he hoped to “hand the mic to crisis counselors” so their counterparts and administrators at other centers around the country could benefit from what they know.

His report makes a dozen specific recommendations ranging from how to improve training to pooling resources, to ensuring that counselors feel they can ask supervisors urgent questions while on risky calls.

One survey finding especially surprised him. Counselors are trained to send local first responders to the caller’s location if they think there’s a high risk of imminent harm or suicide. Some call centers, worried that callers will hang up, prohibit counselors from informing them. Others are urged to tell them, so the knock on the door won’t be a surprise and the person in crisis won’t lose trust in 988. The counselors surveyed said they feel more comfortable being transparent.

Low pay also came up a lot. More than a third of the paid counselors said they earned $20 an hour or less. Some noted that they were helping callers whose crises involved financial distress even as they themselves were experiencing the same economic pressure. “It’s hard to stay in this work if you’re living in poverty,” Fichter told me.

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People in recovery from opioid addiction sometimes need pills for pain. They don’t get them.

That’s when the sheer number of fatal overdoses stunned the nation and many doctors overreacted to stringent federal guidelines by halting prescriptions for longtime pain patients. That response has since loosened a bit – but not for patients in recovery from opioids.

Today, many doctors still under-treat severe pain when people in recovery from addiction are healing from medical procedures. This issue was tackled in a recent New York Times essay by Maia Szalavitz, a journalist whose incisive reporting on addiction has been flagged several times in this space.

Szalavitz was addicted to heroin decades ago, in her 20s. Last summer, she needed two oral surgery procedures. She knew the surgery might cause severe pain that only opioids could effectively relieve but she also feared “reopening a door that could lead me back to my past.” Fortunately, she writes, her long-time primary dentist also was in recovery and helped her navigate the risks.

Before her procedures, she took some preventive steps. She learned what to expect, since anxiety can increase pain, while “having a sense of predictability and control” can reduce it. She also bolstered her social connections, since having them can relieve emotional and physical pain, and lacking them is a risk factor for addiction and relapse. She told her friends that she was having surgery. Her husband picked up her prescription – just a few days’ supply, which was another helpful precaution.

“I felt less anxiety and less pain because I knew relief was available if needed,” Szalavitz writes. Over the course of two surgeries, she took six opioid pills – and there was a moment when she had a vague memory of loving this experience in the past. But it wasn’t seductive or overwhelming, certainly not worth risking the life she has now, she writes: “A life worth living – in which you feel deeply connected to others, have the tools you need to manage distress and have a strong sense of purpose – is the best defense against addiction.”

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Fear of sudden withdrawal may keep some people from using the most effective addiction treatment

The rise of fentanyl presents challenges beyond the obvious: It was involved in more than 75,000 deaths in 2022, according to the most recent CDC projections. But its potency can also cause problems in treatment.

One of the most effective medications used in opioid treatment is buprenorphine, which prevents symptoms of withdrawal while blocking cravings for stronger drugs and producing a minimal high. But if someone takes it while other opioids are in their system, it can trigger sudden and intense withdrawal. That’s especially true of fentanyl, which sticks around longer than other opioids. This reaction, known as precipitated withdrawal, is uncommon, although in recent years, clinicians and fentanyl users have reported an uptick. And that, reports the Tradeoffs podcast, is making some users afraid to try or continue buprenorphine.

A user named Eric Ezzi told the health-policy podcast that for three years, he’d used buprenorphine during the week and heroin on weekends, an approach that allowed him to find steady work, stay out of jail and rebuild relationships, with the hope of eventually quitting heroin for good. Then his dealer began mixing fentanyl into the weekend heroin. Shortly after taking buprenorphine on Monday, Ezzi suddenly felt intense cold and got the shakes while en route to his landscaping job. He hid in a pile of mulch and got through the day by taking the fentanyl.

For the next several weeks, the same thing happened: He’d use fentanyl-laced heroin on weekends, and as soon as he took the buprenorphine on Mondays, he’d go into withdrawal. He soon quit the medication entirely and began using fentanyl seven days a week. He eventually lost his job, stole from his family and was thrown out of the house. Ezzi said he wanted to stop using but was afraid to again try the buprenorphine that had once been his biggest help.

Such cases may be exacerbating a serious problem: the continued underuse of buprenorphine. Although it can be prescribed by most doctors and dispensed by local pharmacies for use at home, barely a fifth of adults with opioid use disorder take it or the other two medications that have proved useful in treating addiction. With fear of buprenorphine growing, Tradeoffs reports, researchers and clinicians are experimenting with alternative approaches, like starting new patients on lower or higher doses of buprenorphine to lessen the risk of precipitated withdrawal. The hope is that these alternatives – if more doctors know about them – will help patients overcome their fears.

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Abortion bans are boosting anxiety among women of child-bearing age, a study finds

Things changed rapidly after the Supreme Court passed the Dobbs decision overturning a woman’s right to an abortion. Thirteen states had passed so-called trigger laws barring abortions that automatically went into effect after the court issued its ruling. Other states continued to protect abortion rights. So, what did these changes mean for women’s mental health? A new study published in JAMA found that in the states that passed abortion bans, anxiety and depression rose among women of child-bearing age.

The study examined federal survey data from December 2021 through January 2023 that asked about symptoms of anxiety and depression. The 700,000 respondents were divided into two broad groups: people who lived in each of the 13 states with trigger bans vs. residents of the 37 states without them. Anxiety and depression increased in both. But it was greater in the states that immediately banned abortion.

A second disturbing study points to another source of stress and trauma for women in states banning abortion. Researchers used data from surveys about sexual violence and estimated that more than half a million rapes took place in the 14 states that ban abortion at any stage. These rapes, they estimate, have so far led to more than 64,000 unwanted pregnancies. Even in states that provide exceptions and permit abortions in cases of rape, the exception only applies if the victim had reported the rape to police, an act taken by only a fifth of rape victims nationwide.

The authors of the paper, published in JAMA Internal Medicine, write that “few (if any) obtained in-state abortions legally.”  An editor’s note from the journal’s top editors brings the point home: “Restricting abortion access to survivors of rape can have particularly devastating consequences.”

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In other news…

Which health and mental health issues are likely to emerge in this year’s presidential campaign? Anand Parekh, an internal medicine physician and chief medical advisor at the Bipartisan Policy Center, gazed into his crystal ball in a commentary for JAMA.

He predicts that Republicans and their likely candidate, Donald Trump, will try to link record drug overdoses to border policies and will rail against Democratic “overreach” in mandating mask-wearing and vaccinations in the fight against COVID-19.

Democrats – and their likely candidate, Joe Biden – will point to high gun violence deaths, including increasing rates of firearm suicides, and tout their success in lowering prescription drug prices. They will also push back on the notion that drug overdoses have anything to do with illegal immigration.

Further down the list, the nation’s mental health crisis could be raised by both sides, Parekh writes, although how their arguments will differ is not yet clear.

The latest issue of The Microdose, a newsletter from the U.C. Berkeley Center for the Science of Psychedelics, piqued our interest on a few topics:

• “Expectancy” – when clinical trial participants expect to get benefit from a psychedelic, skewing the findings of actual benefit – is less of a problem than previously believed, according to a study in Psychological Medicine.
• The EU is funding a large trial of psychedelics for the first time, the Psychedelic Access and Research European Alliance announced.
• And a hat tip to The Microdose for spotting this headline in Vogue:  Are psychedelics retreats the future of wellness travel?

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If you or someone you know is in crisis or experiencing suicidal thoughts, call or text 988 to reach the 988 Suicide & Crisis Lifeline and connect in English 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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