Walter Reed National Military Medical Center, BETHESDA, Md  –   Drug testing in the military, red flags [for abuse], and the use of psychedelics and psychedelic-assisted therapy were some of the topics discussed during the 2024 Substance Use Disorder (SUD) Symposium, recently hosted by the National Capital Region (NCR) Pain Initiative (NCRPI) and Tele-Pain Program at Walter Reed National Military Medical Center.

“The symposium is designed to help clinicians and health care teams identify, prevent, and treat substance use disorders, [which] requires a multifaceted approach including education, research, intervention, and clinical care,” shared Dr. Christopher Spevak, an anesthesiologist and pain physician who directs the NCRPI, Wounded Warrior Pain Care Initiative, and the Pain Management Fellowship.

Symposium keynote speaker, Dr. Michael D. Fox, professor of neurology at the Harvard Medical School, discussed “Common Brain Network Linked to Addiction Across Multiple Substances.” Fox’s research focuses on the development of new and improved treatments for brain disease based on understanding brain networks and the effects of brain stimulation.

“There might be a common brain circuit for addiction across different substances of abuse [such as alcohol and tobacco], and this might be therapeutically relevant to how we engineer our TMS [transcranial magnetic stimulation] coils to [better treat] addiction,” he stated.

“Neuroimaging abnormalities across substances of abuse map to this same brain network,” Fox added. “This network can be targeted with invasive and noninvasive forms of neuromodulation, which may lead to new addiction treatments, and maybe even improvements in our existing addiction treatments,” he said.

Dr. Erin Karschner, forensic toxicologist at Armed Forces Medical Examiner System’s Division of Toxicology at Dover Air Force Base in Delaware, discussed drug testing in the military. The Division of Forensic Toxicology includes four laboratories that support the mission of safety and readiness for U.S. military service members, she explained. The labs include the Military Working Dog, Department of Defense Urine Drug Testing Quality Assurance Special Forensic Toxicology Drug Testing Lab, Postmortem, and Human Performance Toxicology. The latter performs fitness for duty investigations, in addition to driving under the influence (DUI)/while intoxicated (DWI) investigations, drug-facilitated sexual assault investigations, unit sweeps, and military aircraft, ground, and ship (sea) mishaps testing.

“Red Flags and Beyond (Covering Commonly Misused/Abused/Diverted Prescription Medications, Controlled Substances Red Flags Best Practices)” provided the focus of Dr. Mark Garofoli’s presentation. Garofoli serves as director of experiential learning, clinical assistant professor, and clinical pain management pharmacist at the West Virginia University Integrative Pain Management Center. He discussed opioid overdose and deaths, stating that while the U.S. population comprises 5 percent of the world population, the U.S. uses 99 percent of the global supply of hydrocodone, 53 percent of the world’s supply of oxycodone, 61 percent of the global supply of hydromorphone, 37 percent of world’s supply of methadone, and 49 percent of the global supply of buprenorphine.
He explained that prescribers should be aware of red flags for substance abuse, including people seeking to get prescriptions filled out of state; out-of-pocket-only paying patients (i.e., no use of insurance even if available); those seeking the same high quantities of prescription drug repeatedly; and those seeking prescriptions of the same combination of highly addictive drugs.

Red flags for dispensers to be aware of include some of the same as those for prescribers, with the addition of patients seeking early prescription fills/refills; the filling prescriptions for controlled substances for one patient from multiple practitioners; the filling of sequentially numbered controlled substance prescriptions from the same prescriber; dispensing to multiple patients with same last name or address; dispensing high volumes of controlled substances generally; and dispensing a high ratio of controlled to non-controlled drugs.

“A red flag does not automatically mean a prescription is illegitimate, yet it must be resolved,” said Garofoli.

People can report their concerns to the Drug Enforcement Administration at 1-877-RX-Abuse (1-877-792-2873), or online reporting can be done at https://apps.deadiversion.usdoj.gov/rxaor/spring/main?excution=e1s1.
He added that best practices concerning medication use include patient education focused on patient and provider agreements/contracts; treatment goals (pain reduction, improved function, and end of therapy); and proper medication storage and disposal.

Garofoli shared that best practices also include treatment selection such as mental health assessments (psychological evaluation and opioid risk screening), drug interaction reviews, and naloxone education.
Adherence and diversion monitoring are also components of best practices, Garofoli added. This includes pill counts, urine drug monitoring, monitoring for red flags, and Prescription Drug Monitoring Program review.

U.S. Army Lt. Col. Virgil Rivera, Cory Fitzgerald, and Kate Geusic of the Defense Public Health Center discussed the Department of Defense’s Substance Use Education Campaigns. The campaigns include “Own Your Limits,” focused on responsible drinking; “You Can Quit 2,” DOD’s tobacco cessation initiative; and “Too Much To Lose,” addressing prescription and illicit drug misuse. The campaigns are not service-specific.

“Tobacco, alcohol, prescription drug misuse, and illicit and prohibited drug use are threats to military readiness and resilience,” Fitzgerald stated. “Substance use costs the DOD billions of dollars in medical and non-medical costs,” he shared, adding that it requires a multi-prong approach to address substance use and increase readiness amongst the ranks.

Workshops for the symposium focused on functional medicine approach to substance use disorders, understanding the issues with the substance use disorder patient, psychedelics and psychedelic-assisted therapy, and Alcoholics Anonymous.

U.S. Army Maj. (Dr.) Aaron Wolfgang, staff psychiatrist at Walter Reed, discussed psychedelics and psychedelic-assisted therapy. He stated that “the cause of behavioral health conditions is rooted in a neurobiological imbalance [and] medications must be administered chronically to offset the imbalance.”

“The role of medications (psychedelics, stellate ganglion block, etc.) is to enhance the therapy [and] medication [should be] taken infrequently (one to three times total) and only in a supervised medical setting (analogous to surgical anesthesia),” Wolfgang has stated. “No one goes home with anesthesia/psychedelic. Medication is only given in controlled medical settings.”

Psychedelics can promote neurogenesis, metaplasticity, reopening critical periods of learning and cognitive flexibility,” said Wolfgang, who also serves as Novel and Emerging Therapeutics deputy consultant to the Army Office of The Surgeon General, assistant professor at the Uniformed Services University, and adjunct assistant professor for the Yale School of Medicine. He has stated that “Optimizing the delivery of PAT (psychedelic-assisted therapies) with [other] treatments will require further preclinical and clinical research.].”

While Aug. 31 is annually observed as Opioid Misuse Prevention Day and International Overdose Awareness Day, September as Pain Awareness Month, and September 21 as National Opioid Awareness Day, the NCRPI and Tele-Pain Program focuses on improving the quality of care for pain patients in the NCR and beyond by providing resources, education, and treatment daily.

The National Suicide Prevention Lifeline is at 1-800-273-TALK (8255).
The Center for Substance Abuse Treatment (CSAT) can be reached at 1-800-662-HELP.

Provisional data from Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics indicate there were an estimated 107,543 drug overdose deaths in the U.S. during 2023—a decrease of 3 percent from the 111,029 deaths estimated in 2022. This is the first annual decrease in drug overdose deaths since 2018.

New data shows overdose deaths involving opioids decreased from an estimated 84,181 in 2022 to 81,083 in 2023. While overdose deaths from synthetic opioids (primarily fentanyl) decreased in 2023 compared to 2022, cocaine and psychostimulants (like methamphetamine) increased, according to the CDC.