Stories - Blogs

By Adria Williams, Ph.D.

Not All Superheroes Wear Capes, Some Wear Lab Coats
 Short and Long-Term Medicinal Treatment of Physical and Psychological Dependence

Parts I and II explored how opioids act on the brain and how American history — particularly its wars — helped fuel cycles of addiction. Now, we turn to the present. This final installment of “Who Can? We Can, Narcan!” focuses on the lifesaving tools that can interrupt that cycle, from medication-assisted treatment to emergency overdose reversal. In the military and veteran communities, where resilience is both a strength and a barrier to care, these interventions are transforming how we talk about and respond to overdose risk.

During the Vietnam-Era epidemic, researchers were searching for ways to counter opioids’ destructive effects (Payte, 1991). This research resulted in two distinct trajectories, each with different medications and goals. One path focused on helping people overcome opioid dependence, leading to the development of agonist substitution treatment—a long-term method for addressing addiction by substituting a more potent full agonist opioid with a less potent opioid (i.e., levomethadyl acetate, buprenorphine, and methadone; Johnson et al., 2000). It also resulted in the development of a long-acting opioid antagonist that blocks opioid receptors, preventing opioid agonists from plugging back in and reducing relapse risk (Naltrexone; Kirchmayer et al., 2002). Because of how it works, Naltrexone is only given to patients who do not have opioids in their system–typically individuals who are in early recovery or who have completed the detoxification process (Sullivan et al., 2007). While each of these medications has risks and benefits, they share one thing in common: they are all important tools in the fight for sustained recovery (Volkow et al., 2019).

Naloxone to The Rescue!
 Emergency Intervention

So we have powerful, if underutilized, weapons to help in the long-term treatment of opioid use disorder. But how do we decrease opioid overdose deaths in people who may not yet be in recovery or who unwittingly ingest a high-potency opioid? In the event of an overdose, the use of methadone, buprenorphine, or naltrexone is not only unrealistic (given that the person overdosing is likely unconscious), but would be harmful if administered during an opioid overdose; thus is medically contraindicated under those circumstances (McIntyre et al., 2024; World Health Organization, 2009).

Naloxone, on the other hand, is a fast-acting opioid antagonist, which means that it quickly displaces the opioid agonists (pulls the plug), swiftly reversing their effects (McIntyre et al., 2024). Additionally, it blocks the receptor, preventing opioid agonists from plugging back in for a time (think of an outlet cover; McIntyre et al., 2024). It also works quickly (1-2 minutes, depending on the delivery method), reversing the effects of the opioid so that breathing is restored in time to save lives (McIntyre et al., 2024). Fast-acting means the benefits are almost immediate; unfortunately, it also means that it has a short half-life, meaning a second dose may be needed to sustain its effectiveness long enough for the opioid to clear the system (especially with fentanyl). The good news is that it’s safe to do so (McIntyre et al., 2024). And while it is relatively new on the public health/community harm reduction front, it’s been approved by the U.S. Food and Drug Administration (FDA) for more than half a century (McIntyre et al., 2024).

Developed in 1961 and approved in 1971 by the FDA, it was used almost exclusively in hospitals and ambulances to reverse opioid overdoses in surgery or emergency settings (Bennett & Elliot, 2021; McIntyre et al., 2024). Public awareness remained low until the 1990s, when community harm-reduction groups began pushing for broader access (Bennett & Elliot, 2021). In 1995, nalmefene, another opioid antagonist, gained FDA approval, one that is only slightly slower acting (5-15 minutes versus 1-2 minutes for naloxone) but lasts for 8-11 hours compared to ~80 minutes for naloxone (Edinoff et al., 2021). Nalmefene, like naloxone, was only available by prescription and had to be administered by injection, creating barriers to access for both life-saving drugs (Bennett & Elliot, 2021; Edinoff et al., 2021).

In the 2010s, once fentanyl hit the scene, public health authorities shifted course and began endorsing broader naloxone access (Bennett & Elliot, 2021). In 2015, the CDC finally officially recommended community naloxone distribution. In 2018, the FDA approved intranasal naloxone spray and auto-injector pens, and all 50 states allowed pharmacies to dispense naloxone without a prescription (Bennett & Elliot, 2021). Later, in 2023, the FDA approved intranasal naloxone for over-the-counter sale; a landmark win for public health and harm reduction efforts (FDA, 2023a). That same year, they approved intranasal nalmefene as a prescription, and the following year, the first nalmefene hydrochloride auto-injector to reverse opioid overdoses, also available by prescription (FDA, 2023b; FDA, 2024). As of 2025, naloxone sprays are available over the counter in most major pharmacies and online retailers, but the fight isn’t over. While over-the-counter availability may help increase access, cost becomes a barrier for the most at-risk (Gammon et al., 2025).

What’s Happening in the DoW and the VA?
 Department of War (DoW) and Veterans’ Administration (VA) Initiatives

Given that by 2011, opioid overdose fatality rates for veterans being treated at VA hospitals were almost twice that of the civilian population, efforts were already underway to counteract the deadly impact of the epidemic (Bohnert et al., 2011). Beginning with pilot groups in 2013, the VA had launched the first national health-care system-based Opioid Overdose Education and Naloxone Distribution (OEND) program in the country (Oliva et al., 2017). This program led to the VA Rapid Naloxone Initiative (Oliva et al., 2017). Launched in 2018, the initiative provided OENDs to at-risk veterans and equipped VA police and Automated External Defibrillator cabinets with naloxone for emergency use (Oliva et al., 2021). The Uniformed Services University, in collaboration with the Defense Health Agency Research & Engineering Implementation Science Branch, implemented a similar OEND program for use in the Military Health System (MHS; Brendel, 2025; DoD, 2023). This included a clinical-decision support tool in MHS pharmacies to help flag patients at risk of overdose and prompt naloxone co-prescribing, leading to a 79.5% compliance rate for co-prescribing naloxone (Brendel, 2025; DoD, 2023).

We’re not done yet!
 Challenges and Next Steps for the DoW and VA

Several notable challenges remain within DoW and VA. There is inconsistency in the doses prescribed, who prescribes them (pharmacists, physicians, etc.), and in what settings. Uncertainty about “whose job” it is to offer naloxone, and stigma preventing providers from talking with patients about overdose risks, add to these barriers (Sasson et al., 2023). There are also gaps in naloxone distribution regarding demographics and healthcare utilization (Oliva, Bustamante, & Zhu, 2024). Some programs do not have strong mechanisms to ensure patients who receive naloxone are also connected to treatment, overdose education, or further prevention services (Alexander et al., 2024; Knudsen et al., 2025). Within military and veteran systems, there are additional concerns about limited access to naloxone outside clinical settings—particularly in austere environments or among service members stationed in remote areas (DoD, 2023).

To maximize the benefits of this lifesaving intervention, we need to increase access, education, and normalization. Saturation of naloxone availability is an essential component in efforts to decrease opioid-related overdose deaths (Sugarman, Hulsey, & Heller, 2023). Both civilian and military efforts must focus on increasing access for people living in austere areas with limited medical and/or financial resources, as well as for high-risk populations (DoD, 2023). In healthcare settings, educating both clinical and non-clinical staff to normalize conversations about overdose prevention can increase readiness for overdose response and reduce stigma related to opioid use and overdose risk (Knudsen et al., 2025). Finally, greater efforts to connect individuals who have required naloxone to follow-up treatment can transform a life-threatening event in the short term into an opportunity for long-term recovery and stability (Knudsen et al., 2025).

Expanding naloxone access saves lives—but access alone isn’t enough. Providers must normalize conversations about overdose risk and ensure patients are linked to ongoing care. For military and veteran communities, this means aligning lifesaving medication access with consistent education, follow-up, and stigma reduction (Alexander et al., 2024; Oliva et al., 2024).

Expanding naloxone access saves lives, but access alone isn’t enough. Providers and leaders across the military and VA must normalize conversations about overdose risk, link patients to treatment, and reduce stigma at every level of care. The opioid epidemic may have deep historical roots, but its future — one built on education, compassion, and connection — is still ours to shape. Who can? We can, with Narcan.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

Part III References
 Alexander, M., Houck, K. K., Hooker, J., Stratton, M., & Huh, M. (2024). Assessment of a naloxone distribution plan in a veteran population who experienced an opioid-related overdose event. Journal of the American Pharmacists Association, 64(3), 101999. https://doi.org/10.1016/j.japh.2023.12.018

Bennett, A. S., & Elliott, L. (2021). Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities. Translational research: the journal of laboratory and clinical medicine, 234, 43–57. https://doi.org/10.1016/j.trsl.2021.03.001

Bohnert, A. S., Ilgen, M. A., Galea, S., McCarthy, J. F., & Blow, F. C. (2011). Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Medical care, 49(4), 393–396. https://doi.org/10.1097/MLR.0b013e318202aa27

Brendel, H. (2025, February 21). A lifesaving chance: The USU and DHA OEND Program increases naloxone distribution. Uniformed Services University News. https://news.usuhs.edu/2025/02/a-lifesaving-chance-usu-and-dha-oend.html

Edinoff, A. N., Nix, C. A., Reed, T. D., Bozner, E. M., Alvarez, M. R., Fuller, M. C., Anwar, F., Cornett, E. M., Kaye, A. M., & Kaye, A. D. (2021). Pharmacologic and Clinical Considerations of Nalmefene, a Long Duration Opioid Antagonist, in Opioid Overdose. Psychiatry International, 2(4), 365-378. https://doi.org/10.3390/psychiatryint2040028

Gammon, D. G., Gaber, J., Saunders, M., & Zarkin, G. A. (2025). Estimates of first-year OTC naloxone sales in four U.S. states with high rates of opioid overdose deaths: KY, MA, NY, OH. Journal of substance use and addiction treatment, 178, 209762. https://doi.org/10.1016/j.josat.2025.209762

Johnson, R. E., Chutuape, M. A., Strain, E. C., Walsh, S. L., Stitzer, M. L., & Bigelow, G. E. (2000). A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence. The New England journal of medicine, 343(18), 1290–1297. https://doi.org/10.1056/NEJM200011023431802

Kirchmayer, U., Davoli, M., Verster, A.D., Amato, L., Ferri, A., and Perucci, C.A. (2002). A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence. Addiction, 97: 1241-1249. https://doi-org.usu01.idm.oclc.org/10.1046/j.1360-0443.2002.00217.x

Knudsen, H. K., Back-Haddix, S., Andrews-Higgins, S., Goetz, M., Davis, O. A., Oyler, D. R., Walsh, S. L., & Freeman, P. R. (2025). Organizational perspectives on the impacts of scaling up overdose education and naloxone distribution in Kentucky. Addiction Science & Clinical Practice, 20(1), 27. https://doi.org/10.1186/s13722-025-00553-2

McIntyre RS, Harris ME, Todtenkopf MS, Akerman S, and Burgett J (2024). Opioid antagonists: clinical utility, pharmacology, safety, and tolerability. CNS Spectrums 29(6), 542–548. https://doi.org/10.1017/S1092852924002189

Oliva, E. M., Bustamante, R., & Zhu, D. T. (2024). Identifying gaps in Veterans Health Administration (VHA) distribution of lifesaving naloxone. HSR&D Forum. https://www.hsrd.research.va.gov/publications/forum/spring24/default.cfm?ForumMenu=spring24-4

Oliva, E. M., Christopher, M. L., Wells, D., Bounthavong, M., Harvey, M., Himstreet, J., Emmendorfer, T., Valentino, M., Franchi, M., Goodman, F., & Trafton, J. A. (2017). Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration’s national program. Journal of the American Pharmacists Association, 57(2), S168-S179.e4. https://doi.org/10.1016/j.japh.2017.01.022

Oliva, E. M., Richardson, J., Harvey, M. A., & Bellino, P. (2021). Saving Lives: The Veterans Health Administration (VHA) Rapid Naloxone Initiative. The Joint Commission Journal on Quality and Patient Safety, 47(8), 469-480. https://doi.org/10.1016/j.jcjq.2021.06.004

Payte J. T. (1991). A brief history of methadone in the treatment of opioid dependence: a personal perspective. Journal of psychoactive drugs, 23(2), 103–107. https://doi.org/10.1080/02791072.1991.10472226

Sasson, C., Dieujuste, N., Klocko, R., Basrai, Z., Celedon, M., Hsiao, J., Himstreet, J., Hoffman, J., Pfaff, C., Malmstrom, R., Smith, J., Holstein, A., & Johnson-Koenke, R. (2023). Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments. Academic Emergency Medicine, 30(4), 289-298. https://doi.org/10.1111/acem.14683

Sullivan, M. A., Garawi, F., Bisaga, A., Comer, S. D., Carpenter, K., Raby, W. N., Anen, S. J., Brooks, A. C., Jiang, H., Akerele, E., & Nunes, E. V. (2007). Management of relapse in naltrexone maintenance for heroin dependence. Drug and Alcohol Dependence, 91(2-3), 289–292. https://doi.org/10.1016/j.drugalcdep.2007.06.013

Sugarman OK, Hulsey EG, Heller D. Achieving the Potential of Naloxone Saturation by Measuring Distribution. JAMA Health Forum. 2023;4(10):e233338. https//doi.org/10.1001/jamahealthforum.2023.3338

U.S. Department of Defense, Defense Health Agency. (2023). Opioid overdose education and naloxone distribution (OEND) program. https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/OEND-Program

U.S. Food and Drug Administration (2023a, March 29). FDA approves first over-the-counter naloxone nasal spray. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray

U.S. Food and Drug Administration (2023b, May 23). FDA approves prescription nasal spray to reverse opioid overdose. https://www.fda.gov/news-events/press-announcements/fda-approves-prescription-nasal-spray-reverse-opioid-overdose

U.S. Food and Drug Administration. (2024, August 7). FDA approves first nalmefene hydrochloride auto-injector to reverse opioid overdose. https://www.fda.gov/news-events/press-announcements/fda-approves-first-nalmefene-hydrochloride-auto-injector-reverse-opioid-overdose

Volkow, N. D., Jones, E. B., Einstein, E. B., & Wargo, E. M. (2019). Prevention and Treatment of Opioid Misuse and Addiction: A Review. JAMA psychiatry, 76(2), 208–216. https://doi.org/10.1001/jamapsychiatry.2018.3126

World Health Organization. (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (Annex 12, Prescribing guidelines). World Health Organization. https://www.ncbi.nlm.nih.gov/books/NBK143167/

84
The number of military members killed in motorcycle crashes in FY 25, according to an article in Stars and Stripes -- US military’s rate of motorcycle accidents proves costly in lives, care and lost duty time. By service branch, the fatality numbers were:

• Navy: 45 deaths (30 sailors, 15 Marines)
• Army: 28 deaths
• Air Force: 11 deaths

The weekly Research Update contains the latest news, journal articles, and useful links from around the web. Some of this week's topics include:

● Identifying Priorities in Behavioral Health for Military Youth and Families.
● Alcohol Consumption Per Capita and Suicide: A Meta-Analysis.
● Cognitive Behavioral Therapy for Insomnia in People With Chronic Disease: A Systematic Review and Meta-Analysis.
● Eye Movement Desensitization and Reprocessing Therapy in Persons With Personality Disorders: A Randomized Clinical Trial.

By Adria Williams, Ph.D.,

As a Suicide Prevention Subject Matter Expert, most of my time these days is spent learning and sharing information to prevent suicide among military-connected individuals. That focus means I’m not always up to date on the evolving landscape of substance use disorders (SUDs), risk management, and treatment.

PARTs I & II: Biology and History 
As a Suicide Prevention Subject Matter Expert, most of my time these days is spent learning and sharing information to prevent suicide among military-connected individuals. That focus means I’m not always up to date on the evolving landscape of substance use disorders (SUDs), risk management, and treatment.

At one point in time, I provided SUD treatment across levels of care in a range of settings in both DC and Baltimore. It should be noted that that “point in time” started last century and ended 15 years ago. So when I volunteered to write this blog, I initially thought, “I could write this with my eyes closed.” (Ah, the hubris of doctorate-level providers, amirite?) My wake-up call was as swift as it was humbling—the field has changed as much as the neighborhood I grew up in.

After overthinking it, I narrowed the list to three possible topics:

• “Being a Substance Use Disorder Treatment Provider Ain’t for the Faint of Heart” – The Importance of Self-Care for SUD Treatment Providers
• “They Used to Prescribe Narcotic Painkillers Like Pez Dispensers—Now All I Got After Surgery Was Acetaminophen and Lidocaine Patches” – Navigating the Balance Between Pain Management and Reduced Opioid Access
• “Who Can? We Can, Narcan!” – A Naloxone Primer

While all three could be informative, I landed on the third—because it allows me to both learn and teach something. So, without further ado…

Let’s Plug In: Science Lesson: How Opioids Work in the Brain

Receptors, Agonists, and Antagonists
Before we can talk about policies, treatment, or even naloxone, we have to understand the science. Opioids don’t just change behavior — they literally rewire the brain. This first part of the “Who Can? We Can, Narcan!” series breaks down what happens inside the nervous system when opioids enter the body. Whether you’re a clinician, a prevention specialist, or someone supporting military-connected individuals, knowing some basics will lay the foundation for understanding both addiction, the dangers of overdose, and a path to recovery.

Picture your brain as a wall covered in power outlets. These outlets control different functions in the body—they are receptors. They are activated when they get “plugged in”. Below are the “plug” options that determine power flow:

• Agonists: Both sockets have plugs = full power
• Partial Agonists: one socket is plugged in = partial power
• Antagonists: outlet is covered = No power + blocks other plugs

Now, the brain has different types of “outlets” that power all sorts of things. Today, we’re going to focus on one type: μ-(Mu) opioid receptors (MOR). They regulate pain relief, improve mood, and decrease breathing to restore homeostasis after stress or injury. The plugs that provide power to these receptors are called opioid agonists, opioid partial agonists, and opioid antagonists–clever, huh? (Kosten & George, 2002)

Tolerance
Your brain naturally produces endogenous opioid agonists (e.g., endorphins) that plug into MORs. But if the pain is chronic, your body may habituate to the effect over time. When that happens, the opioid agonist is still plugged in, but the power provided is no longer strong enough to alleviate pain or improve mood–this is tolerance (DuPen, Shen, & Ersek, 2007). Tolerance occurs for both endogenous and exogenous opioid agonists (opioids from an external source).

Dependence and Withdrawal
With tolerance comes repeated/increased use; subsequently, the brain adapts, reducing its own endorphin production and increasing other endogenous chemicals to maintain relative balance in affected brain systems. Now, the body relies on opioids just to feel normal, which is considered physical dependence (Kosten & George, 2002).

When the exogenous opioid is removed, the resulting chemical imbalance can lead to agitation and anxiety, severe muscle and bone pain, diarrhea and vomiting, chills and/or sweats, insomnia, not to mention increased breathing, blood pressure, and heart rate. That’s withdrawal, and the lived experience is even worse than the description sounds. While not considered life-threatening in most cases, it is agonizing. People experiencing it have reported “feeling like they were dying” or “wishing they would die.” A person in this position is no longer taking opioids to “feel good,” they are taking them to prevent themselves from feeling wretched (Kosten & George, 2002).

Overdose 
Quick reminder, the opioid receptors that manage pain and boost mood also suppress breathing. The pattern of increased frequency/strength of opioid use eventually can lead to too much activation → oxygen deprivation → opioid overdose (Bateman, Saunders, & Levitt, 2023). If oxygen deprivation lasts several minutes, it can cause brain/organ damage, which can be fatal. While increased use to offset tolerance and withdrawal can lead to eventual overdose, an overdose can occur with just one use if the opioid is potent enough. This is especially relevant in today’s fight to prevent opioid overdose deaths. The introduction of such potent opioids, such as fentanyl, into the drug market, sometimes mixed with or disguised as less potent opioids, has skyrocketed overdose rates (Bateman et al., 2023).

The way opioids act on the brain helps explain why they’ve followed us through history — from the battlefield to the bedside. Next, we’ll trace how America’s wars and public policies turned medical innovation into recurring opioid epidemics, setting the stage for the crisis we face today.

PART II: History

Wars and Waves: The Interconnected History of Opioid Use and Wars in the US

In Part I, we explored the neurobiology of opioids and how easily the brain’s reward system can be hijacked. But the opioid epidemic isn’t just a story of molecules — it’s a story of people, policy, and history. Each major U.S. conflict has left behind not only physical and psychological scars but also a trail of opioid dependence. This section of the series follows the timeline of how war, medicine, and public perception intersected to create wave after wave of opioid crises.

It Actually Began with Flowers
Opioid use has been around for a long time…like a really long time. There’s evidence that opium from the poppy flower (an exogenous opioid agonist) was first cultivated in ancient Europe close to 8000 years ago (Salavert et al., 2020). That said, opioids didn't really start showing up in American History until the 1600s. From there, our wars turn everyday use into epidemics.

We’ll start in the 1770s, when the US was fighting its first war —the war for its independence…

Wars

Revolutionary War 
During the Revolutionary War (1775-1783), laudanum (a mix of opium and alcohol) gained popularity as a go-to for pain relief by American soldiers (Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces [CPDTM-SUD], 2013). Laudanum and opium use continued following the war as common household remedies, prescribed especially to women for “nervous complaints” and to infants as sleep aids (Levitt, 2013). In the early 1800s, morphine was discovered and was quickly embraced by the medical community as a “miracle drug” for pain and anxiety (Dormandy, 2012).

Civil War
The Civil War (1861-1865) is, to date, the bloodiest war in American history, so it’s not surprising that morphine and laudanum use surged during this time (Courtwright, 2001). Of note, immediately before the Civil War, the invention of the hypodermic syringe and needle enabled direct injection of morphine, revolutionizing pain control — and unfortunately accelerating opioid dependence (Dormandy, 2012). These advances, in conjunction with the devastating mental and physical injuries of the war, resulted in the nation’s first opioid epidemic; it was during this time that Opioid Use Disorder was coined “the soldier’s disease”(CPDTM-SUD, 2013).

In Germany, shortly thereafter, a chemist at Bayer Pharmaceutical Company developed heroin, deemed a safe, non-addictive alternative to morphine (DEA Museum). This proved to be untrue with dire and enduring consequences; as it turns out, heroin is cheaper, more potent, and more addictive than morphine (Murrin, 2008).

Vietnam War and the “War on Drugs”
The Vietnam War era (1950s-1970s) was the next time opioid use reached epidemic levels, fueled by the intersection of returning soldiers and increased availability of heroin in marginalized neighborhoods (Bergen-Cico, 2015). Although this epidemic was less severe than the one following the Civil War, it led to another type of war, the “War on Drugs,” criminal justice-based policies designed to limit drug supply and use (Farber, 2022). The criminalization of drug use/dependence led to limited access to treatment, an increase in overdose deaths, and spikes in co-occurring infectious disease epidemics such as Hepatitis C and HIV/AIDS through the 1980s into the 1990s (Gostin, 1991).

“The War on Terror” and the Waves of the Current Epidemic
In the mid-1990s, deceptive marketing of prescription opioids (POs) ushered in today’s opioid epidemic (Kolodny, 2015; Van Zee, 2009). This epidemic is unique in that it has been marked by distinct waves and persisted for close to 30 years, making it the longest and deadliest in U.S. history (Jenkins, 2021). The first wave began around 1999, and from 1999 to 2011, the PO overdose death rates nearly quadrupled (Chen, Hedegaard, & Warner, 2014).

It is within this opioid wave that the “War on Terror” Takes place. By 2008, more than 10% of active duty service members were taking opioids either legally or illegally, and between 2000 and 2009, PO overdose deaths among Veterans Health Administration patients nearly doubled (Bohnert et al., 2014; CPDTM-SUD, 2013).

After peaking in 2010, prescriptions for POs declined due to efforts to limit access. Heroin use rebounded in 2010, sparking the 2nd wave in the epidemic with heroin overdose deaths peaking in 2016 (CDC, 2025; Rudd et al., 2016). In 2013, however, a more potent opioid drug hit the illicit drug market, marking the 3rd wave and quickly surpassing all other opioids in terms of potency and mortality: fentanyl (CDC, 2025; Ciccarone, 2017).

Fentanyl (and its analogs) and the 4th Wave
Fentanyl was initially synthesized by pharmaceutical companies in the 1950s for hospital use in surgery and treating severe pain (U.S. Drug Enforcement Administration [DEA], 2020). As such, it is 50 times more potent than heroin and 100 times more potent than morphine (DEA, 2020). In 2013, illicitly manufactured fentanyl and its analogs entered the U.S. drug supply, often passed off as heroin, prescription opioids, and/or benzodiazepines, exposing new, unsuspecting users to the highly potent drug (Schueler & Toner, 2017). In terms of impact, by 2016, Fentanyl surpassed both heroin and prescription drugs as the leading cause of opioid-involved overdose deaths in the U.S. (Ciccarone, 2021; NIDA, 2024).

After a slight decline in Opioid overdose deaths from 2017 to 2018, a new pattern in the epidemic has emerged. Described as the “4th wave,” it is unique as it is not due to the decline in one substance as another increases. It is instead due to polydrug use and overdose deaths, specifically fentanyl with methamphetamine and/or cocaine (Ciccarone, 2021). While COVID-19 did not cause the 4th wave, it did exacerbate its impact, further increasing use and related deaths (Manchikanti et al., 2022).

As of 2023, opioid overdose deaths were nearly ten times as high as it was in 1999 (NIDA, 2024). Today, fentanyl-related substances are thought to be responsible for ~75% of opioid overdose deaths in the US (NIDA, 2024).

History shows that with every war, our understanding of opioids evolves — and so does the toll they take. But the story doesn’t end with despair. In Part III, we’ll meet the new heroes in this fight: the scientists, clinicians, and military health professionals driving lifesaving change through education, innovation, and access to medications like naloxone.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

Part I & II References
Bateman, J. T., Saunders, S. E., & Levitt, E. S. (2023). Understanding and countering opioid-induced respiratory depression. British Journal of Pharmacology, 180(7), 813–828. https://doi.org/10.1111/bph.15580

Bergen-Cico, D. K. (2015). War and Drugs: The Role of Military Conflict in the Development of Substance Abuse. United Kingdom: Taylor & Francis. https://doi.org/10.4324/9781315631226

Bohnert, A. S., Ilgen, M. A., Trafton, J. A., Kerns, R. D., Eisenberg, A., Ganoczy, D., & Blow, F. C. (2014). Trends and regional variation in opioid overdose mortality among Veterans Health Administration patients, fiscal year 2001 to 2009. The Clinical journal of pain, 30(7), 605–612. https://doi.org/10.1097/AJP.0000000000000011

Centers for Disease Control and Prevention. (2025, June 9). Understanding the opioid overdose epidemic. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

Chen LH, Hedegaard H, Warner M. ( 2014). Drug-Poisoning Deaths Involving Opioid Analgesics: United States, 1999–2011. NCHS Data Brief No. 166. Hyattsville, MD: Natl. Cent. Health Stat. [Google Scholar]

Ciccarone, D. (2017). Fentanyl in the U.S. heroin supply: A rapidly changing risk environment. International Journal of Drug Policy, 46, 107–111. https://doi.org/10.1016/j.drugpo.2017.06.010

Ciccarone D. (2021). The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Current Opinion in Psychiatry, 34(4):344-350. https://doi.org/10.1097/YCO.0000000000000717

Committee on Prevention, Diagnosis, Treatment, and Management of Substance Use Disorders in the U.S. Armed Forces, Board on the Health of Select Populations, Institute of Medicine, O’Brien, C. P., Oster, M., & Morden, E. (Eds.). (2013, February 21). Substance use disorders in the U.S. armed forces. National Academies Press. https://doi.org/10.17226/13441

Courtwright D. T. (2001). Dark paradise: A history of opiate addiction in America. Cambridge, MA: Harvard University Press. https://www.hup.harvard.edu/books/9780674005853

DEA Museum. (n.d.). Heroin bottle: Bayer & Co. Retrieved from https://museum.dea.gov/museum-collection/collection-spotlight/artifact/heroin-bottle

Dormandy, T. (2012). Opium: Reality’s Dark Dream. Yale University Press. https://yalebooks.yale.edu/book/9780300175325/opium/

DuPen, A., Shen, D., & Ersek, M. (2007). Mechanisms of opioid-induced tolerance and hyperalgesia. Pain Management Nursing, 8(3), 113–121. https://doi.org/10.1016/j.pmn.2007.02.004

Farber, D. ed. (2022). The War on Drugs: A History. NYU Press Scholarship Online. https://doi.org/10.18574/nyu/9781479811359.001.0001

Gostin, L. O. (1991). The interconnected epidemics of drug dependency and AIDS. Harvard Civil Rights–Civil Liberties Law Review, 26, 114–184. https://scholarship.law.georgetown.edu/facpub/761

Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559–574. https://doi.org/10.1146/annurev-publhealth-031914-122957

Jenkins, R. A. (2021). The fourth wave of the US opioid epidemic and its implications for the rural US: A federal perspective. Preventive Medicine, 152, 106541. https://doi.org/10.1016/j.ypmed.2021.106541

Kosten, T. R., & George, T. P. (2002). The neurobiology of opioid dependence: implications for treatment. Science & Practice Perspectives, 1(1), 13–20. https://doi.org/10.1151/spp021113

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1.9 Million
The number of children who receive care in the Military Health System, according to an article in the journal Alcohol: Clinical and Experimental Research --Diagnosing prenatal alcohol exposure and fetal alcohol syndrome in military-connected children: Insights from US military data claims, 2016–2023.

One thousand four hundred seventy six unique children had any diagnosis between 2016 and 2023 (PAE (Prenatal Alcohol Exposure) only: 301; FAS (Fetal Alcohol Syndrome) only: 1061; both: 114). Period prevalence was 0.42 cases per 1000 children. Cumulative incidence was 0.34 cases per 1000 children for 2017–2023 using 2016 as a 1-year washout. Average age at any diagnosis was 8.3 years. Factors associated with increased likelihood of diagnosis were male sex; being in guardianship; sponsor of senior officer rank; and sponsor affiliated with the Air Force or Other Service branch. Factors associated with decreased likelihood of diagnosis included Black or Other race; being a stepchild; sponsor of junior enlisted or junior officer rank; and sponsor in the Marine Corps.

The Center for Deployment Psychology’s Research Team is excited to introduce a new effort to improve our assessment of disturbing dreams.

The Big Picture
The existing measures of negative dreams often utilize a specific term such as bad dreams, nightmares, or disturbing dreams to assess the severity or frequency of the dreams. Just as assessments use various terms for negative dreams, so do individuals. It is not surprising that individuals report different levels of negative dreams across the various measures. We suggest that there are two reasons that reports may vary. First, the term utilized in the measure may not align with the individual’s preferred term or definition for their negative dream. For example, some individuals consider bad dreams to be less severe than nightmares, so they may not report nightmares if they consider their dreams to not be severe. Additionally, bad dreams and nightmares are often stigmatized, and individuals may not be comfortable using these terms. We suggest a new approach may improve our ability to identify individuals experiencing disturbing dreams.

Participant Eligibility and Study Activity
We are seeking subject matter experts (clinicians and doctoral researchers) in dreams and/or nightmares to take part in a Lawshe study informing the development of a new measure. Participation includes reviewing the current version of the measure and providing feedback on the included items. We estimate this will take approximately xx minutes. You may be asked to provide feedback at a second time point.

Get Involved
To learn more or to take part in this exciting project, please email cat-research.cdp@usuhs.edu with a brief description of your professional experience with dreams and/or nightmares.

8%
The percentage of the incarcerated population in the U.S. comprised of veterans, according to an article in the journal Federal Practitioner -- Examining Moral Injury in Legal-Involved Veterans: Psychometric Properties of the Moral Injury Events Scale.

One hundred veterans with a history of incarceration completed the MIES (Moral Injury Events Scale) and an adapted version for legal-involved persons (MIES-LIP). More than 90% of participants reported potentially morally injurious experiences in the legal context. While confirmatory factor analysis did not support the proposed factor structure of the MIES-LIP, an exploratory factor analysis supported a 2-factor solution characterized by self- and other-directed moral injury.

By: Linda Thompson, Jaime Rodden, Maegan M. Paxton Willing

This Suicide Prevention Month, CDP’s research team is taking a proactive approach to one of the most pressing challenges facing the military community. Suicide among service members and veterans remains a public health concern, with rates far exceeding those seen in the general population. Although many factors are associated with suicide risk, sleep problems have emerged as a critical, yet under-recognized factor. Prior work consistently demonstrates that poor sleep is not only common among military personnel, but also closely linked to worsening mood, hopelessness, and suicidal thoughts.

View the DREAMSS Study Flyer

In recognition of this, our team is collaborating with researchers at San Diego State University and the National Center for PTSD to utilize sleep health interventions to reduce suicide risk through a population health approach. This study recognizes the many ways in which we can support service members’ sleep and mental health by teaching health sleep habits as a proactive strategy, providing specific training to leaders regarding the importance of sleep for the military mission, and providing individual recommendations for problematic sleep using mobile health applications (Insomnia Coach). Our team hopes that by improving sleep health that we may also improve their mental health. Learn more about this study at https://cdp.usuhs.edu/blog/research-cdp-introducing-sleep-ed-mc-study.

Additionally, one of the greatest challenges with suicide prevention is that suicidal thoughts can change rapidly, often over a matter of hours. Traditional research methods typically rely on participants recalling their experiences over the past week or month, but this retrospective approach prevents identification of important warning signs and patterns. While we raise awareness, we also know that effective prevention relies on better understanding the problem. One way to address this is through the use of ecological momentary assessments, which assess suicidal thoughts and related symptoms several times throughout the day within an individual’s daily life. Inclusion of common wearables, such as Fitbits, allow us to observe the effects of sleep on suicide risk. By pairing physiological data with participants’ self-report, we gain a clearer picture of how disrupted sleep and changes in mood and suicidal thoughts are interwined.

This approach allows us to 1) detect early warning signs of suicidal crisis that might otherwise be missed, 2) identify specific times of heightened vulnerability, such as after poor sleep, and 3) pinpoint critical intervention windows when support could be more effective. Learn more about this study at https://cdp.usuhs.edu/blog/research-cdp-introducing-dreamss-study.

Ultimately, we hope these efforts will contribute to building targeted, scalable interventions for the broader military and veteran communities. If we can understand when suicide risk escalates and why, we can help develop tools that deliver support in the moments when service members and veterans need it the most.

Get Involved
To learn more about our current research efforts examining this important relationship, visit our website at cdp.usuhs.edu/research.

by Ariana Bazzi and Jaime Rodden

An exciting collaboration between the Uniformed Services University Department of Medical and Clinical Psychology and the Center for Deployment Psychology is investigating a standardized training program for eating disorders within military settings.

About the PreparED Study
The PreparED study centers around a standardized online educational program on eating disorders. The 85 minute course consists of an introduction by Dr. Tanofsky-Kraff describing the unique presentation of eating disorders in military populations followed by modules on Assessment, Medical Complications, Treatment, and Military-Relevant Considerations. Ultimately, the PreparED curriculum is intended to give healthcare providers a clear and comprehensive all-in-one guide to understanding eating disorders in the military.

The Big Picture
Eating disorders appear at higher rates among our service members compared to the general population. This increased vulnerability is often tied to the unique pressures of military life, such as constant exposure to high-stress environments, and the significant impact of conditions including, but not limited to posttraumatic stress disorder and major depressive disorder. To address this critical need, Columbia University Medical Center, has developed a publicly accessible online course and partnered with our study team to train military providers. The curriculum is designed specifically for future healthcare professionals, including students and trainees to provide them with the essential knowledge and practical tools to better understand, identify, and support individuals affected by eating disorders, ultimately aiming to improve care for those who have served.

Participant Eligibility and Study Activities
Medical providers and providers from the Defense Health Agency (DHA) serving as a primary care or other direct care provider to military-connected patients are eligible to participate in the study. Participants are provided with a SurveyMonkey link to take a pre-survey. Participants are then asked to complete the online 70 minute course and post-course survey within a month from completion of the pre-survey.

Get Involved
For more information about the PreparED study, visit our website at https://cdp.usuhs.edu/Eating-Disorders-Base or reach out to the Research Assistant Ariana at Ariana.Bazzi.ctr@usuhs.edu To participate in the study, review the informed consent document: https://www.surveymonkey.com/r/QXSTNH2

By Adria Williams, Ph.D.

Hopefully, the title hooked you. Now what am I talking about? And who is “us”? The “what” is conversations about firearm safety and suicide prevention. The “who” is healthcare providers. Let’s take a few steps back…

Why Firearm Safety Matters in Suicide Prevention

In the U.S. and military communities, firearms play a uniquely lethal role in suicide:

• Civilian deaths: Firearms account for ~52% of suicide deaths (Centers for Disease Control; CDC, 2024).
• Active-duty service members (Department of Defense; DOD, 2024):
           Firearms: 7% of attempts → 65% of deaths
           Self-poisoning (overdose): 54% of attempts →< 6% of deaths
• Lethality gap:
           Self-poisoning: ~2 in 10 attempts end in death
           Firearms: ~9 in 10 attempts end in death (Johns Hopkins, 2023; Wintemute, 2019)

Takeaway: Even if the number of attempts doesn’t change, reducing firearm access can save lives because of how disproportionately lethal firearms are. That points us toward one of the most effective interventions: Lethal Means Safety Counseling (LMSC), which includes conversations about firearm safety and suicide prevention.

The Trust Problem

If patients don’t trust us to have these conversations, we miss out on one of the most effective strategies to prevent suicide.

How do we know trust is low? Anestis and colleagues (2021) examined which messengers are most and least trusted when discussing firearms and suicide. The most trusted groups: military personnel, veterans, and law enforcement—all communities with firearm experience.

And who’s at the bottom? Us! Physicians and other medical professionals—just above casual acquaintances and celebrities. This pattern was consistent across gender, race, and gun ownership status. In other words, we are only slightly more trusted than strangers!

Other studies echo the theme. For example, half of firearm owners report believing it is never appropriate for healthcare providers to discuss firearms (Betz et al., 2016).

So—what’s driving this lack of trust, and what can we do about it? While we don’t have data explicitly outlining the pitfalls, we can extrapolate based on what we know about how trust is built (and eroded) in interactions with healthcare providers. Below four missteps are illustrated along with how to turn each into a rapport building-conversation

Common Patient Concerns (and Solutions)

“We judge their choices.”→ Biased Communication
 Example: A military spouse shares concerns about being alone at home with her children during her husband’s upcoming deployment. She’s excited about a firearm safety class she just completed in preparation for buying a gun for protection. The provider’s eyes widen:

“Wait—you have three small children at home. Is that really safe?”

Problem: The provider is communicating a biased opinion about gun owners with small children. This assumes that the patient is being inherently unsafe when she is actually discussing proactive steps to be a safe firearm owner. The message the patient hears:

“You are a bad parent; you are putting your children in danger!”

Trust building response:
 “I’m glad you’re looking forward to the class. Firearm safety is especially important with kids in the home, and it sounds like you’ve already taken proactive steps, that’s awesome. So when does your husband deploy…”

Solution: Be culturally responsive. As providers, it is our responsibility to not only respect the values and norms of a patient’s culture (e.g., military-connected), but to also be aware of the intersectionality of different aspects of a patient’s identity (e.g., parent, military spouse, gunowner, etc.) within that culture.

Issue: “We want to take their guns.”→ Ignore Patient Autonomy
 Example: A service member discloses suicidal thoughts without intent or plan. The provider responds:

“That’s concerning. You’ll need to turn your weapon over to your command until we can be sure you are safe.”

Problem: While reducing access to lethal means may ultimately be necessary, the unilateral approach strips autonomy and discourages future disclosure.

Trust building response:

“Sounds like things have been really difficult. Can you tell me more about what led to those thoughts? From there, we can come up with a plan together to help keep you safe during those tough times.”

Solution: Balance patient safety and autonomy. Conduct a thorough risk assessment with curiosity and concern, then collaborate to develop a Safety Plan with strategies the patient is both willing and able to implement.

Issue: “We don’t know anything about firearms.”→ Lack of Competence
 Example: In 2015, an E3 preparing for a Permanent Change of Station (i.e., moving to a new duty station) worries about storing her firearms. The provider shrugs:

“That’s easy, just buy a gun safe and ship it with your household goods” (HHG).

Problem: This overlooks the cost of the safe itself, its weight, and the fact that safes counted against HHG weight allowances at the time—revealing a notable knowledge gap.

Trust building response:

“Let’s start with how you’re storing your firearms now. Then we can check local laws at your new duty station and figure out the best plan together.”

Solution: Be informed. You don’t need to be a firearm expert, but you do need to demonstrate competence in firearm safety basics and relevant regulations/laws. Online courses (e.g., virtual firearm safety, LMSC training) can help, as can familiarity with DoD and local regulations

Issue: “We act like know-it-alls.”→ Maintaining the Knowledge Gap
 Example: A patient says:

“I’m thinking of buying a gun. I don’t feel safe at home.”

The provider replies:

“Trust me, that’s not the way to stay safe. Get a dog instead.”

Problem: The asymmetrical tone conveys “I know better than you—this isn’t up for debate.” It dismisses the patient’s concern, weakens rapport, and misses an opportunity to bridge the knowledge gap between provider and patient.

Trust building response:
 Provider:

“No one likes feeling unsafe at home. What’s making you feel this way?”

Patient:

“There’s been more crime in my neighborhood.”

Provider:

“I understand. I do worry about relying on firearms for protection, because research shows that having a gun at home can nearly triple the risk of homicide. Other security options can reduce break-ins without increasing risk of harm. Would you be open to talking through some of those together?”

Solution: Ask, explain, collaborate. Gather more information, share rationale, and avoid assumptions. Provide explanations to reduce asymmetry.

Closing Thought

We may not earn everyone’s trust overnight. But we can take steps—through cultural responsiveness, collaboration, competence, and transparency—to be worthy of the trust we are striving for. The trust it takes to save lives

Resources
CALM (Counseling on Access to Lethal Means): Training offered by the Suicide Prevention Resource Center that provides information on how to have a discussion with patients about lethal means. (https://sprc.org/online-library/calm-counseling-on-access-to-lethal-means/)

Means Matter: Website from the Harvard T. H. Chan School of Public Health with resources & trainings on the topic of reducing suicidal individuals’ access to lethal means. (https://www.hsph.harvard.edu/means-matter/)

Defense Suicide Prevention Office: Webpage with a suite of lethal means safety tools. (https://www.dspo.mil/Home/Tools/Resource-Library/Lethal-Means-Safety/)

VA Lethal Means Safety & Suicide Prevention: Webpage with resources, including information on secure firearm storage. (https://www.va.gov/reach/lethal-means/)

“Let’s Talk about Your Guns” Podcast: A series of podcasts from the Center for the Study of Traumatic Stress about gun safety. (https://www.cstsonline.org/suicide-prevention-program/podcasts/lets-talk-about-your-guns)

Project Child Safe: Firearm safety education program that offers free educational resources, including gun locks. (https://projectchildsafe.org)

Stanford University - Clinicians and Firearms 2.0: This CME/CE course equips clinicians with the knowledge and communication strategies needed to discuss firearm injury prevention with patients effectively. It includes modules on firearm basics and safe storage. (https://online.stanford.edu/courses/som-ycme0051-clinicians-and-firearms-20-curriculum-firearm-injury-prevention-medical?utm_source=chatgpt.com)

BulletPoints Project - Preventing Firearm Injury: A free, self-paced course that takes about 60 minutes to complete. It provides an opportunity for participants to earn one Continuing Education (CE) credit. The course covers firearm injury prevention and safe storage options. (https://continuingeducation.bulletpointsproject.org/courses/preventing-firearm-injury/)

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

References

• Anestis, M. D., Bond, A. E., Bryan, C. J., Bryan, A. O., & Knox, K. L. (2021). Trust in healthcare providers and willingness to discuss firearm safety: Results from a national survey. Preventive Medicine, 145, 106445. https://doi.org/10.1016/j.ypmed.2020.106445
• Betz, M. E., Miller, M., Barber, C., Beaty, B., & Miller, I. (2016). Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety, 33(6), 502–511. https://doi.org/10.1002/da.22486
• Centers for Disease Control and Prevention (CDC). (2024). Suicide mortality in the United States, 2000–2022. NCHS Data Brief, No. 509. https://www.cdc.gov/nchs/products/databriefs/db509.htm
• U.S. Department of Defense, Defense Suicide Prevention Office. (2024, November 14). Annual Report on Suicide in the Military, Calendar Year 2023 (ARSM CY 2023). https://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf
• Wintemute, G. J. (2019). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 40, 5–19. https://doi.org/10.1146/annurev-publhealth-031914-122535