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Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

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theconversation.com – Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University – 2024-10-16 07:28:00

Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

Patients suffering withdrawal from fentanyl and xylazine can require intensive care.

SDI Productions/E+ Collection via Getty Images

Kory London, Thomas Jefferson University

Unimaginable pain and restlessness. Vomiting so frequent and forceful that it can perforate the esophagus. Blood pressure and heart rate so high that they damage the heart. Sweating that drenches clothing and sheets. Nerve sensitivity that makes even the softest touch agonizing. A prolonged panic attack that is provoked and worsened by even mundane activities and conversations.

The withdrawal symptoms from “tranq dope” – the combination of the synthetic opioid fentanyl and the animal tranquilizer xylazine that dominates Philadelphia’s street opioids supply – tend to be far worse than those experienced by even the most severe heroin users of the past.

So it’s no surprise that people will do whatever they can to forestall them. That includes walking out of the hospital before their care is complete.

I’m an associate professor of emergency medicine who has spent a decade as an emergency physician working in Center City and South Philadelphia. I’ve spent most of that time directing projects to improve care for people who use drugs.

Beginning in 2022, our team – a group of emergency and addiction physicians – began experimenting with new approaches to treating tranq dope withdrawal.

We were able to reduce the likelihood of these patients leaving the hospital before treatment was complete by more than half – from 10% to just under 4%.

We also reduced the severity of their suffering, lowering their withdrawal scores – or how they rate their pain and other symptoms – by more than half.

Traditional treatments don’t work

Before tranq dope, treating opioid withdrawal in the emergency department was relatively straightforward, with well-studied, conventional protocols.

For patients without chronic pain, health care providers started buprenorphine, known by its brand name Suboxone, when patients showed signs of withdrawal.

Buprenorphine works by partially, rather than fully, stimulating opioid receptors in the body. This subtle difference relieves symptoms of withdrawal but reduces the risk of overdose if patients continue to use other opioids. It quite literally saves lives.

Tranq dope, however, created a much larger set of challenges.

Fentanyl and other synthetic opioids are dozens to hundreds of times more powerful than heroin. Xylazine, meanwhile, adds symptoms of sedative withdrawal to the mix: restlessness, adrenaline activation and agitation.

As synthetic opioids became pervasive in Philadelphia’s drug supply over the past decade, overdose deaths in the city tripled. Those numbers are beginning to decline, for reasons that remain unclear.

Torso of person wearing black tank top and dirty bandage from bicep to wrist

Fear of withdrawal can even prevent people with serious medical conditions from going to the hospital.

Jeff Fusco/The Conversation US, CC BY-ND

Meanwhile, tranq users started to share buprenorphine horror stories. They refused the medication due to a phenomenon called “precipitated withdrawal.” Precipitated withdrawal is a condition in which taking buprenorphine paradoxically makes withdrawal symptoms worse, rather than improving them. Due to the severity of their symptoms, some patients who precipitate severely even require treatment in the intensive care unit.

Furthermore, when patients did accept buprenorphine, their withdrawal symptoms were no longer being effectively controlled, even with very high doses. We were adrift.

Patients demand discharge

When people with severe substance use disorders are hospitalized, even compassionate staff members sometimes lose patience.

Being confined to a stretcher in a loud, chaotic environment, in withdrawal, with prior traumatic health care experiences, can lead patients to act out. They might repeatedly hit call bells, use inappropriate language, make impulsive decisions or sneak drugs into the hospital.

This creates a lot of stress for nurses and staff, and distracts from the care of others.

So when patients demand to leave before treatments are complete, exhausted care teams often quickly acquiesce. Traditionally, this was termed leaving “against medical advice,” but is now called “patient-directed discharge.”

Patient-directed discharge is associated with higher rates of mortality, permanent disability and rehospitalization.

Rates of patient-directed discharge can be 10 to 50 times higher in people with an opioid use disorder compared with the general public.

A cycle of mistrust can also form, where the expectation that a patient may leave again leads to a less engaged care team, which in turn can make patients more likely to leave.

At staff meetings, some compared the challenges of caring for these individuals to those experienced in the hardest parts of the COVID-19 pandemic.

New approach needed

Many physicians have been reticent to consider other options for treating opioid withdrawal. I believe there are two key reasons for this. One is the lack of Food and Drug Administration approval for alternative treatments. The other is that federal regulations consider addiction a behavioral rather than medical condition, effectively separating most doctors from the addiction care of these individuals.

As fentanyl and xylazine became ubiquitous in Philadelphia’s street dope, local hospitals reported astronomical rates of patient-directed discharge among these patients. This was happening despite the best efforts of hospital staffs that are deeply experienced in conventional opioid withdrawal treatment.

In 2021, an editorial in the Annals of Internal Medicine journal advocated for the use of short-acting opioids for some patients’ opioid withdrawal – which is already common practice in Canada. Short-acting opioids are medications doctors traditionally use to treat acute pain.

Philadelphia hospitals started experimenting with using these previously verboten medications. That included our team at Jefferson Health.

Under a bridge, a person crouches under a blanket in the foreground and two people talk in background

Overdose deaths in Philadelphia spiked as fentanyl and xylazine became more prevalent.

Jeff Fusco/The Conversation US, CC BY-ND

Oxycodone, hydromorphone and ketamine

By using short-acting opioids such as oxycodone or hydromorphone, combined with a low-dose version of buprenorphine, we prevented precipitated withdrawal and treated opioid withdrawal and pain in our patients.

The low-dose bupenorphine can be increased over time to steady doses. This shows patients that the medication is safe and provides them a bridge to long-term treatment.

The short-acting opioids replace the opioids that their bodies are frantically searching for. They reduce their pain and misery, and are decreased when their symptoms are controlled.

Patients with opioid use disorder will often do whatever they can to stay out of the hospital due to fear of withdrawal. Asking how withdrawal symptoms are managed, therefore, is often their first priority when hospitalized. We see this even when they have conditions that require complicated and time-sensitive treatments.

Owing to the vast amounts of opioids many of our patients use, we also give them additional strong medications, or “adjunctive therapies,” to supplement the effects of the short-acting opioids and low-dose buprenorphine. One is ketamine, an anesthetic that affects nerve impulses and is increasingly being used to treat depression, post-traumatic stress discorder and substance use disorders.

Ketamine is also an effective pain medication that can extend the effects of opioids and reduce the number of doses needed.

We additionally add muscle relaxants – which work similarly to xylazine – along with nausea medications and IV fluids, to help give patients a chance at healing.

Side effects and future problems

In patients who received our medications, the risks of serious side effects were minimal. The few patients who suffered serious adverse effects had other acute medical problems that could have contributed to the side effects. Almost all the side effects we saw were mild and resolved on their own.

As powerful synthetic opioids and other contaminants become pervasive in more U.S. cities, more emergency departments will need to figure out how to care for patients in withdrawal so that they don’t leave treatment.

It is our hope that this work will inspire others to do a better job of providing relief to patients suffering from this complicated and severe condition.The Conversation

Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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How nonprofits abroad can fill gaps when the US government cuts off foreign aid

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theconversation.com – Susan Appe, Associate Professor of Public Administration and Policy, University at Albany, State University of New York – 2025-01-30 07:50:00

How nonprofits abroad can fill gaps when the US government cuts off foreign aid

The U.S. Agency for International Development distributes a lot of foreign aid through local partners in other countries.

J. David Ake/Getty Images

Susan Appe, University at Albany, State University of New York

The U.S. government gives other nations US$68 billion of foreign assistance annually – more than any other country. Over half of this sum is managed by the U.S. Agency for International Development, including funds for programs aimed at fighting hunger and disease outbreaks, providing humanitarian relief in war zones, and supporting other lifesaving programs such as the President’s Emergency Plan for AIDS Relief.

President Donald Trump suspended most U.S. foreign aid on Jan. 20, 2025, the day he took office for the second time. The next day, Secretary of State Marco Rubio issued a stop-work order that for 90 days halted foreign aid funding disbursements by agencies like USAID.

A week later, dozens of senior USAID officials were put on leave after the Trump administration reportedly accused them of trying to “circumvent” the aid freeze. The Office of Management and Budget is now pausing and evaluating all foreign aid to see whether it adheres to the Trump administration’s policies and priorities.

I’m a scholar of foreign aid who researches what happens to the U.S. government’s local partners in the countries receiving this assistance when funding flows are interrupted. Most of these partners are local nonprofits that build schools, vaccinate children, respond to emergencies and provide other key goods and services. These organizations often rely on foreign funding.

A ‘reckless’ move

Aid to Egypt and Israel was spared, along with some emergency food aid. The U.S. later waived the stop-work order for the distribution of lifesaving medicines.

Nearly all of the other aid programs remained on hold as of Jan. 29, 2025.

Many development professionals criticized the freeze, highlighting the disruption it will cause in many countries. A senior USAID official issued an anonymous statement calling it “reckless.”

InterAction, the largest coalition of international nongovernmental organizations in the U.S., called the halt contrary to U.S. global leadership and values.

Of the $35 billion to $40 billion in aid that USAID distributes annually, $22 billion is delivered through grants and contracts with international organizations to implement programs. These can be further subcontracted to local partners in recipient countries.

When this aid is frozen, scaled back or cut off altogether, these local partners scramble to fill in the gaps.

The State Department manages the rest of the $68 billion in annual U.S. foreign aid, along with other agencies, such as the Peace Corps.

Marco Rubio, standing in a hallway, holding something in his hand.

The start of Marco Rubio’s tenure as U.S. secretary of state was marked by chaos and confusion regarding foreign aid flows.

Kevin Dietsch/Getty Images

How local nonprofits respond and adapt

While sudden disruptions to foreign aid are always destabilizing, research shows that aid flows have fluctuated since 1960, growing more volatile over the years. My research partners and I have found that these disruptions harm local service providers, although many of them manage to carry on their work.

Over the years, I have conducted hundreds of interviews with international nongovernmental organizations and these nonprofits’ local partners across Latin America, Africa and Asia about their services and funding sources. I study the strategies those development and humanitarian assistance groups follow when aid gets halted. These four are the most common.

1. Shift to national or local government funding

In many cases, national and local governments end up supporting groups that previously relied on foreign aid, filling the void.

An educational program spearheaded by a local Ecuadorian nonprofit, Desarrollo y Autogestión, called Accelerated Basic Cycle is one example. This program targets young people who have been out of school for more than three years. It allows them to finish elementary school – known as the “basic cycle” in Ecuador – in one year to then enter high school. First supported in part by funding from foreign governments, it transitioned to being fully funded by Ecuador’s government and then became an official government program run by the country’s ministry of education.

2. Earn income

Local nonprofits can also earn income by charging fees for their services or selling goods, which allows them to fulfill their missions while generating some much-needed cash.

For example, SEND Ghana is a development organization that has promoted good governance and equality in Ghana since its founding in 1998. In 2009, SEND Ghana created a for-profit subsidiary called SENDFiNGO that administers microfinance programs and credit unions. That subsidiary now helps fund SEND Ghana’s work.

Bangladesh Rural Advancement Committee and the Grameen Bank, which is also in Bangladesh, use this approach too.

3. Tap local philanthropy

Networks such as Worldwide Initiatives for Grantmaker Support and Global Fund for Community Foundations have emerged to promote local philanthropy around the world. They press governments to adopt policies that encourage local philanthropy. This kind of giving has become easier to do thanks to the emergence of crowdfunding platforms.

Still, complex tax systems and the lack of incentives for giving in many countries that receive foreign aid are persistent challenges. Some governments have stepped in. India’s corporate social responsibility law, enacted in 2014, boosted charitable incentives. For example, it requires 2% of corporate profits to go to social initiatives in India.

4. Obtain support from diaspora communities

Diasporas are people who live outside of their countries of origin, or where their families came from, but maintain strong ties to places they consider to be their homeland.

Local nonprofits around the globe are leveraging diaspora communities’ desire to contribute to economic development in their countries of origin. In Colombia, for example, Fundación Carla Cristina, a nongovernmental organization, runs nursery schools and provides meals to low-income children.

It gets some of its funding from diaspora-led nonprofits in the U.S., such as the New England Association for Colombian Children, which is based outside of Boston, and Give To Colombia in Miami.

A push for the locals to do more

Trump’s stop-work order coincided with a resurgence of a localization push that’s currently influencing foreign aid from many countries.

With localization, nations providing foreign aid seek to increase the role of local authorities and organizations in development and humanitarian assistance. USAID has been a leading proponent of localization.

I believe that the abruptness of the stop-work order is likely to disrupt many development projects. These projects include support to Ukrainian aid groups that provide emergency humanitarian assistance and projects serving meals to children who don’t get enough to eat.

To be sure, sometimes there are good reasons for aid to be halted. But when that happens, sound and responsible donor exit strategies are essential to avoid the loss of important local services.The Conversation

Susan Appe, Associate Professor of Public Administration and Policy, University at Albany, State University of New York

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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How satellites and AI help fight wildfires today

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theconversation.com – John W. Daily, Research Professor in Thermo Fluid Sciences, University of Colorado Boulder – 2025-01-30 07:48:00

How satellites and AI help fight wildfires today

The wind and terrain can quickly change how a fire, like this one near Los Angeles in January 2025, behaves.

AP Photo/Marcio Jose Sanchez

John W. Daily, University of Colorado Boulder

As wind-driven wildfires spread through the Los Angeles area in January 2025, fire-spotting technology and computer models were helping firefighters understand the rapidly changing environment they were facing.

That technology has evolved over the years, yet some techniques are very similar to those used over 100 years ago.

I have spent several decades studying combustion, including wildfire behavior and the technology used to track fires and predict where wildfires might turn. Here’s a quick tour of the key technologies used today.

Spotting fires faster

First, the fire must be discovered.

Often wildfires are reported by people seeing smoke. That hasn’t changed, but other ways fires are spotted have evolved.

In the early part of the 20th century, the newly established U.S. Forest Service built fire lookout towers around the country. The towers were topped by cabins with windows on all four walls and provided living space for the fire lookouts. The system was motivated by the Great Fire of 1910 that burned 3 million acres in Washington, Idaho and Montana and killed 87 people.

Two people stand on a fire tower with windows on all sides, looking out over the forest.

Before satellites, fire crews watched for smoke from fire towers across the national forests.

K. D. Swan, U.S. Forest Service

Today, cameras watch over many high-risk areas. California has more than 1,100 cameras watching for signs of smoke. Artificial intelligence systems continuously analyze the images to provide data for firefighters to quickly respond. AI is a way to train a computer program to recognize repetitive patterns: smoke plumes in the case of fire.

NOAA satellites paired with AI data analysis also generate alerts but over a wider area. They can detect heat signatures, map fire perimeters and burned areas, and track smoke and pollutants to assess air quality and health risks.

Forecasting fire behavior

Once a fire is spotted, one immediate task for firefighting teams is to estimate how the fire is going to behave so they can deploy their limited firefighting resources most effectively.

Fire managers have seen many fires and have a sense of the risks their regions face. Today, they also have computer simulations that combine data about the terrain, the materials burning and the weather to help predict how a fire is likely to spread.

Fuel models

Fuel models are based on the ecosystem involved, using fire history and laboratory testing. In Southern California, for example, much of the wildland fuel is chaparral, a type of shrubland with dense, rocky soil and highly flammable plants in a Mediterranean climate. Chaparral is one of the fastest-burning fuel types, and fires can spread quickly in that terrain.

For human-made structures, things are a bit more complex. The materials a house is made of – if it has wood siding, for example – and the environment around it, such as how close it is to trees or wooden fences, play an important role in how likely it is to burn and how it burns.

How scientists study fire behavior in a lab.

Weather and terrain

Terrain is also important because it influences local winds and because fire tends to run faster uphill than down. Terrain data is well known thanks to satellite imagery and can easily be incorporated into computer codes.

Weather plays another critical role in fire behavior. Fires need oxygen to burn, and the windier it is, the more oxygen is available to the fire. High winds also tend to generate embers from burning vegetation that can be blown up to 5 miles in the highest winds, starting spot fires that can quickly spread.

Today, large computer simulations can forecast the weather. There are global models that cover the entire Earth and local models that cover smaller areas but with better resolution that provides greater detail.

Both provide real-time data on the weather for creating fire behavior simulations.

Modeling how flames spread

Flame-spread models can then estimate the likely movement of a fire.

Scientists build these models by studying past fires and conducting laboratory experiments, combined with mathematical models that incorporate the physics of fire. With local terrain, fuel and real-time weather information, these simulations can help fire managers predict a fire’s likely behavior.

Examples of how computer modeling can forecast a fire’s spread. American Physical Society.

Advanced modeling can account for fuel details such as ground-level plant growth and tree canopies, including amount of cover, tree height and tree density. These models can estimate when a fire will reach the tree canopy and how that will affect the fire’s spread.

Forecasting helps, but wind can change fast

All these tools are made available to firefighters in computer applications and can help fire crews as they respond to wildfires.

However, wind can rapidly change speed or direction, and new fires can start in unexpected places, meaning fire managers know they have to be prepared for many possible outcomes – not just the likely outcomes they see on their computer screens.

Ultimately, during a fire, firefighting strategy is based on human judgment informed by experience, as well as science and technology.The Conversation

John W. Daily, Research Professor in Thermo Fluid Sciences, University of Colorado Boulder

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Gen Z seeks safety above all else as the generation grows up amid constant crisis and existential threat

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theconversation.com – Yalda T. Uhls, Founder and Executive Director of the Center for Scholars & Storytellers and Assistant Adjunct Professor in Psychology, University of California, Los Angeles – 2025-01-30 07:47:00

Gen Z seeks safety above all else as the generation grows up amid constant crisis and existential threat

Asked to rate the importance of 14 personal goals, Gen Z reported ‘to be safe’ as the top goal.

Darya Komarova/Getty Images

Yalda T. Uhls, University of California, Los Angeles

After many years of partisan politics, increasingly divisive language, finger-pointing and inflammatory speech have contributed to an environment of fear and uncertainty, affecting not just political dynamics but also the priorities and perceptions of young people.

As a developmental psychologist who studies the intersection of media and adolescent mental health, and as a mother of two Gen Z kids, I have seen firsthand how external societal factors can profoundly shape young people’s emotional well-being.

This was brought into sharp relief through the results of a recent survey my colleagues and I conducted with 1,644 young people across the U.S., ages 10 to 24. The study was not designed as a political poll but rather as a window into what truly matters to adolescents. We asked participants to rate the importance of 14 personal goals. These included classic teenage desires such as “being popular,” “having fun” and “being kind.”

None of these ranked as the top priority. Instead, the No. 1 answer was “to be safe.”

A house burning down with huge flames.

It lurks everywhere: Gen Z’s perception of danger is further shaped by events like the recent fires devastating Los Angeles.

Agustin Paullier/AFP via Getty Images

What was once taken for granted

The findings are both illuminating and heartbreaking. As a teenager, I did countless unsafe things. My peers and I didn’t dwell on harm; we chased fun and freedom.

Whereas previous generations may have taken safety for granted, today’s youth are growing up in an era of compounded crises — school shootings, a worsening climate crisis, financial uncertainty and the lingering trauma of a global pandemic. Even though our research did not pinpoint the specific causes of adolescent fears, the constant exposure to crises, amplified by social media, likely plays a significant role in fostering a pervasive sense of worry.

Despite data showing that many aspects of life are safer now than in previous generations, young people just don’t feel it. Their perception of danger is further shaped by events like the recent fires that devastated Los Angeles, reinforcing a belief that danger, possibly caused by global crises like climate change, lurks everywhere.

This shift in perspective has profound implications for the future of this generation and those to come.

Especially vulnerable time

Adolescence, like early childhood, is a pivotal period for brain development. Young people are particularly sensitive to their surroundings as their brains evaluate the environment to prepare them for independence.

This developmental stage – when the capacity to regulate emotions and critically assess information is still maturing – makes them especially vulnerable to enduring impacts.

Studies show that adolescents struggle to put threats into context. This makes them particularly vulnerable to fear-driven messaging prevalent in both traditional and social media, which is further amplified by political rhetoric and blame-shifting. This vulnerability has implications for their mental health, as prolonged exposure to fear and uncertainty has been linked to increased rates of anxiety, depression and even physical health issues.

So when the media that Gen Z consumes are dominated by fear – be it through headlines, social media posts, political rhetoric or even storylines in movies and TV – it could shape their worldview in ways that may reverberate for generations to come.

Enduring generational impact

Historical events have long been shown to shape the worldview of entire generations.

For instance, the Great Depression primarily impacted the daily lives of the Silent Generation, those born between 1928 and 1945. Moreover, its long-term effects on financial attitudes and security concerns echoed into the Baby Boomer generation, influencing how those born between 1946 and 1964 approached money, stability and risk throughout their lives.

Similarly, today’s adolescents, growing up amid a series of compounded global crises, will likely carry the imprint of this period of heightened fear and uncertainty well into adulthood. This formative experience could shape their mental health, decision-making and even their collective identity and values for decades to come.

In addition, feelings of insecurity and instability can make people more responsive to fear-based messaging, which could potentially influence their political and social choices. In an era marked by the rise of authoritarian governments, this susceptibility could have far-reaching implications because fear often drives individuals to prioritize immediate safety over moral or ideological ideals.

As such, these dynamics may profoundly shape how this generation engages with the world, the causes they champion and the leaders they choose to follow.

Room for optimism?

Interestingly, “being kind” was rated No. 2 in our survey, irrespective of other demographics. While safety dominates their priorities, adolescents still value qualities that foster connection and community.

This finding indicates a duality in their aspirations: While they feel a pervasive sense of danger, they also recognize the importance of interpersonal relationships and emotional well-being.

Our findings are a call to look at the broader societal context shaping adolescent development. For instance, the rise in school-based safety drills, while intended to provide a sense of preparedness, may unintentionally reinforce feelings of insecurity. Similarly, the apocalyptic narrative around climate change may create a sense of powerlessness that could further compound their fears and leave them wanting to bury their heads in the sand.

Understanding how these perceptions are formed and their implications for mental health, decision-making and behavior is essential for parents, storytellers, policymakers and researchers.

I believe we must also consider how societal systems contribute to the pervasive sense of uncertainty and fear among youth. Further research can help untangle the complex relationship between external stressors, media consumption and youth well-being, shedding light on how to best support adolescents during this formative stage of life.The Conversation

Yalda T. Uhls, Founder and Executive Director of the Center for Scholars & Storytellers and Assistant Adjunct Professor in Psychology, University of California, Los Angeles

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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