TTENTION TO DEPRESSION AND suicide in physicians is long overdue. As early as 1858, physicians in England observed that a higher suicide rate exists among physicians than the general population. 1 Since the 1960s, research confirmed physicians' higher suicide rate and identified depression as a major risk factor. 2,3 Most strikingly, suicide is a disproportionately high cause of mortality in physicians, 4 with all published studies 5,6 indicating a particularly high suicide rate in female physicians.Inattention to depression and suicide in physicians sharply contrasts with heightened attention to physicians' smoking-related mortality. Since the 1960s, declines of 40% to 60% have oc-Author Affiliations: Employment Law Center and the

Novel synthetic opioids (NSO) include various analogs of fentanyl and newly-emerging non-fentanyl compounds. Together with illicitly manufactured fentanyl (IMF), these drugs have caused a recent spike in overdose deaths, while deaths from prescription opioids have stabilized. NSO are used as stand-alone products, as adulterants in heroin, or as constituents of counterfeit prescription medications. During 2015 alone, there were 9,580 deaths from synthetic opioids other than methadone. Most of these fatalities were associated with IMF rather than diverted pharmaceutical fentanyl. In opioid overdose cases where the presence of fentanyl analogs was examined, analogs were implicated in 17% of fatalities. Recent data from law enforcement sources show increasing confiscation of acetylfentanyl, butyrylfentanyl and furanylfentanyl, in addition to non-fentanyl compounds such as U-47700. Since 2013, deaths from NSO in the United States are 52 for acetylfentanyl, 40 for butyrylfentanyl, 128 for furanylfentanyl and 46 for U-47700. All of these substances induce a classic opioid toxidrome which can be reversed with the competitive antagonist naloxone. However, due to the putative high potency of NSO and their growing prevalence, it is recommended to forgo the 0.4 mg initial dose of naloxone and start with 2 mg. Because NSO offer enormous profit potential, and there is strong demand for their use, these drugs are being trafficked by organized crime. NSO present major challenges for medical professionals, law enforcement agencies and policymakers. Resources must be distributed equitably to enhance harm reduction though public education, medication-assisted therapies and improved access to naloxone.