In an effort to enhance patient safety in Opioid Treatment Programs (OTPs), the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members reviewed the literature, regulatory actions, professional guidances, and OTPs’ experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every OTP should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, ECG assessment, risk stratification, and prevention of drug interactions) for all patients, and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining ECGs as indicated by a particular patient’s risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.

One fundamental question that is still not resolved is whether acupuncture needles must be inserted in specific points to have their greatest effects. In the majority of large RCTs recently conducted in Germany, acupuncture was significantly more effective than doing nothing but not than sham acupuncture. Only for one study of chronic knee pain was acupuncture superior to sham. Brain imaging with functional magnetic resonance (fMRI) and positron emission tomography (PET) may be helpful but is still in its early stages. Several studies have shown differences between the way the deep central areas of the brain respond to genuine acupuncture compared with sham. Acupuncture can clearly produce complex changes that are relevant to pain transmission and perception, though it is still uncertain how specific these are. Similar changes have been seen after the application of placebo cream and after hypnosis. Aprevious paper discussed the likely central role of the limbic system in acupuncture, evidenced by euphoria and out of body experiences. There may be a good deal of common ground between acupuncture, placebo treatments, hypnosis, and even manipulative treatments. This understanding could offer a way out of the sterile debate about whether acupuncture is merely a placebo: acupuncture could be one effective way of stimulating responses within these deep areas of the brain, though not the only way.

Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

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Deaths involving prescription and illicit opioids are on the rise, which is an issue of increasing concern to health care professionals, policymakers, and the public. However, because medical examiners, coroners, and other practitioners do not use uniform standards and case definitions in classifying such drug-related deaths, the incidence and prevalence data are challenging to analyze and difficult to interpret, and thus form a poor basis for crafting effective responses. To address this situation, the Substance Abuse and Mental Health Services Administration convened a Consensus Panel and charged it with devising uniform standards and case definitions that can assist medical examiners, coroners, public health officials, and others in consistently distinguishing between deaths that were caused by a certain opioids and deaths in which such a drug was detected but was not a major cause of or contributor to the death. The consensus statement presented here incorporates the panel's recommendations in four key areas.

Patients receiving acupuncture sometimes manifest phenomena such as laughter or crying; varying degrees of relaxation or euphoria are quite common. Rarely, epileptic fits occur. Patients vary considerably in their responsiveness to acupuncture: some fail to respond at all while others (strong reactors) experience marked effects. It is widely recognised that fear of acupuncture generally precludes a therapeutic response, whereas belief in the efficacy of the treatment is irrelevant. All these phenomena must presumably have a neurophysiological explanation. This paper proposes that they may, at least in part, be caused by processes occurring in those brain structures that are classified as forming the limbic system. The paper briefly reviews the history and status of the limbic system idea, discusses how limbic system structures may contribute to the phenomena in question, and offers a number of predictions which would allow these hypotheses to be tested.

In favour of self-acupuncture, this is a useful way to prolong the effects of acupuncture when the response is only brief or patients cannot attend frequently. If the patient is capable and the condition is suitable for self-acupuncture, patients can be taught how to do it and then seen for review. Patients should be provided with complete information sheets, and one example is presented. Against self-acupuncture, patient safety is paramount and would be compromised by teaching them how to do acupuncture. In addition, serious accidents have happened with self-acupuncture, including a death. Other arguments against it are that it is less effective than standard acupuncture, the patient misses out on the therapeutic relationship, and safer alternative methods exist.

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