Rate this article for a chance to win
Have you heard talk of the “opioid epidemic?” Do you know what opioids are? In 2015, more Americans died from drug overdoses (over 52,000) than from traffic accidents or shootings, according to data from the Centers for Disease Control and Prevention (CDC). Of those fatal overdoses, more than 33,000 involved opioids (such as heroin, oxycodone, and fentanyl).

Even if you don’t think you know anyone who is affected by the opioid epidemic, you may, at some point, find yourself in a position to save a life. That’s because many opioid overdoses can be reversed with timely medical treatment. The more you know about opioid addiction and treatment, the more you can help if you encounter a friend or family member who needs it. Read on to find out what the opioid epidemic is all about, and how you may be able to help.

What is the opioid epidemic?

The opioid epidemic is how researchers are referring to the problem our nation is having with opioid addiction. In the past 15 years, the rates of prescription opioid misuse and heroin abuse have risen dramatically. As a result, the rate of overdose deaths from opioids has quadrupled, according to the CDC.

What are opioids?

Opioids (sometimes called opiates) are a class of drugs commonly used to treat pain. The illegal drug heroin is also an opioid. There are three common types of opioids:

These can be prescribed by a health care provider to treat moderate to severe pain. Common prescription opioids include hydrocodone (Vicodin®), oxycodone (OxyContin®), morphine, and methadone.

Fentanyl is the name of a synthetic opioid that is extremely powerful (about 50 times more so than heroin), and therefore highly dangerous. It is intended only to treat severe pain, such as from advanced cancer. Recently, fentanyl has been illegally manufactured to sell on the street. Street fentanyl is sometimes mixed with other drugs such as cocaine and heroin, and it isn’t always labeled as fentanyl. Researchers believe that the rapid increase in overdose deaths is in part due to the increase in people taking illegally made fentanyl. Methadone is also a synthetic opioid that can be prescribed for pain relief. Because it doesn’t give the same “high” associated with other opioids, it’s sometimes used in drug treatment programs to help people reduce their dependence on opioids.

Heroin is an illegal, highly addictive drug. It is usually injected but can also be smoked or snorted. In the past few years, the rate of heroin use has increased in most age groups and at all income levels.

How does opioid addiction happen?

“Addiction happens when a person uses a drug, starts needing more of the drug over time to feel the same effect, becomes physically dependent on it, and then does almost anything to get it,” says Dr. Margie Skeer, substance abuse prevention researcher and associate professor at Tufts University School of Medicine in Boston. This can happen to anyone, even when they are not intending to misuse opioids. Over time, repeatedly using opioids changes the way nerve cells work in the brain. These nerve cells become so used to having opioids around that when the opioid is taken away, the body experiences a negative reaction—called withdrawal—usually in the form of severe aching, fever, sweating, and chills. Because withdrawing from opioids can be extremely uncomfortable and painful, people will keep using the drug to avoid feeling sick.

“My brother was hooked on heroin when he was in the military. He tested positive on a drug test and they sent him to rehab. It cost him a lot: his career, his rank, his dignity. But he got clean. Now he is a nurse.”
Rebekah, city and state withheld

“A girl I used to go to high school with recently overdosed on heroin. She was a social butterfly and not someone you would expect to have an addiction.” —Melanie, Newark, DelawareHow is the opioid epidemic affecting high school students?

Most high school students don’t abuse opioids. In fact, only about 1–3 percent of teens report having misused Vicodin® or OxyContin® in the past year, and less than 1 percent say they’ve used heroin, according to data from the 2016 Monitoring the Future study. Even though opioid misuse and deaths have continued to rise in the adult population, high school seniors’ rates of past-year prescription opioid misuse have gone down in the past five years.

That’s all good news. But 9 out of 10 adults who have a substance use disorder say they started using before they were 18, so it’s important to be aware of that risk now. Plus, getting in trouble for using drugs or alcohol as a teen could reduce the number of opportunities available to you now or in the future (e.g., college, playing sports, getting a good job). In the worst-case scenario, misusing prescription drugs (or heroin) could mean overdose or death. As you prepare for adulthood, it’s incredibly important that you understand the issues surrounding opioid abuse and dependence—so that you can help end the epidemic.

“The younger people are when they start using substances (even alcohol), the greater their chances of developing a problem with drugs when they get older. This is at least partly due to how drugs can impact the way the brain develops during the teen years. For example, the more often teens use drugs, the more the brain makes connections around drug use, making it more likely they’ll want to continue using drugs as they get older.”
Dr. Skeer

“My big brother passed away this year from a heroin overdose. He became addicted to opioids after having surgery. He tried to recover but never did. He was over 90 days clean when he relapsed and overdosed.” —Jamie, Clemson, South CarolinaHow have opioids become such a problem?

It’s never easy to pinpoint the exact causes of a drug epidemic, but research has shed some light on a few of the factors that are contributing to it:

  • The number of opioids prescribed for pain has risen dramatically in the past 15 years. According to a study in the journal Pediatrics, the rate of heath care professionals prescribing opioids to teens nearly doubled between 1997 and 2010.
  • People sometimes share their prescription pain medications with others, often without realizing that this could harm the other person. Most teens and adults who abuse prescription drugs get them from a friend or relative, according to the National Institute on Drug Abuse and a 2014 study in JAMA Internal Medicine.
  • The synthetic opioid fentanyl has become much more prevalent because of an increase in the illegal manufacturing of it. Fentanyl contributed to a 72 percent increase in overdose deaths caused by synthetic opioids (other than methadone) between 2014 and 2015.
  • When people become addicted to a prescription opioid pain medication, they sometimes switch to using heroin because it produces a similar effect, can be cheaper, and doesn’t require a doctor’s prescription, according to the National Institute on Drug Abuse.
  • Childhood trauma is a major contributing factor to the opioid epidemic. This doesn’t mean most people who experienced childhood trauma will become addicted to opioids—but according to a 2012 study published in Addiction, most people who develop opioid addiction experienced severe childhood trauma. This is a reminder that it’s important to prioritize self-care and seek out other supports following traumatic experiences.

“Two-thirds of people with opioid addictions have had at least one severely traumatic childhood experience, and the greater your exposure to different types of trauma, the higher the risk becomes,” wrote Maia Szalavitz in Scientific American. “We need to help abused, neglected, and otherwise traumatized children before they turn to drugs for self-medication when they hit their teens.”

Other risk factors for opioid abuse include:

  • Depression
  • Alcohol use disorder, or heavy use of alcohol and/or other recreational drugs
  • Personality disorder
  • Poverty

Can a single dose of a prescribed opioid lead to opioid addiction?

Not likely. If you’ve ever broken a bone or had your wisdom teeth pulled, there’s a chance you’ve been prescribed an opioid for the pain. When used exactly as they are prescribed, opioid medications can be helpful in reducing pain. Addiction occurs when someone repeatedly uses a substance to the point that the reward system in their brain becomes desensitized to that substance. This is why a person may start to need the substance in larger amounts to get the same (or reduced) effect.

That said…

  • A single dose of heroin or an opioid painkiller (if it’s not prescribed to you, or if you overdose) can cause death.
  • Some people are genetically predisposed to addiction; their first experience of a drug may be especially powerful, increasing the chance that they will use again.

What are the red flags for people using pain medications?

9 out of 10 adults who have a substance use disorder say they started using before they were 18For people who are taking an opioid medication that’s been prescribed to them, red flags may include if they feel like they can’t stop using the meds, or are taking them for general feel-good reasons, rather than to reduce the pain. If this is happening to you or someone you know, seek help (see below). Patients who know they are at higher risk of addiction can choose to refuse opioid prescriptions for pain, opting for non-narcotic medications instead. Some pain may also be managed with physical activity, meditation, or massage. 

“When I was little I always wondered what my dad was doing going to the bathroom so often and why he would go from being in a really good mood to sometimes a bad mood very quickly. My dad died when I was eight from a drug overdose at his house, and I will never forget that day. Addiction is a nasty thing that I never want to see someone go through ever again.”
Camryn, Memphis, Tennessee

What can you do to help stop the opioid epidemic? 

Never share your medications with anyone, and dispose of prescription pills properly.

Any time you have unused, expired, or unwanted prescription medications, dispose of them as soon as possible and don’t give them to anyone else. This helps reduce harm from others intentionally or accidentally taking the medication, according to the Food and Drug Administration.

  • Contact your local police station or fire department to find out if they have a prescription drug take-back program, or if they know of one in your community.
  • Check disposemymeds.org to find a pharmacy near you that will take them.

If your only option is to throw the medicine away, follow these FDA guidelines:

  • Mix the medication with something inedible, such as coffee grounds, kitty litter, or dirt
  • Place the mixture in a sealed plastic bag
  • Throw the bag in the trash
  • Scratch out all of your personal information from the prescription bottle so it can’t be read, and dispose of it

What does an opioid overdose look like?

The signs of opioid overdose are pretty consistent and predictable. They include:

  • Small pupils
  • Droopy arms and legs, and the inability to stand or walk
  • Itching
  • Slurred speech
  • Shallow and uneven breathing
  • Being unresponsive (e.g., not answering to their name, not responding to physical stimulation such as rubbing your knuckles into their sternum)
  • Loss of consciousness

When time is running out and the person may be dying, signs include:

  • Pale face
  • Blue lips
  • Gurgling chest sounds

“People are at highest risk for overdose after they have a period of time when they weren’t using opioids and then they use again. The body isn’t used to the drug anymore, and if they use the same amount that they did before stopping, it can overload the brain and body and lead to an overdose.”
Dr. Skeer

What to do if someone may have overdosed on opioids: Call 911 immediately

  • Act quickly: Most deaths occur one to three hours after the overdose, so you have a window where you can help. You do not need to be positive the person has overdosed on opioids (or any other substance) before calling 911.
  • Get medical help: Any suspected overdose requires emergency medical help. When people survive an overdose, it is because professional help was available.
  • Tell the 911 dispatcher: Let them know if the person’s breathing has slowed or stopped and if they are unresponsive. Give the dispatcher the exact location.
  • Be aware of Good Samaritan laws: In most states, people who seek help with a suspected overdose are protected against drug-related criminal charges under “Good Samaritan” laws (also known as 911 Immunity Laws). For information about your state, see Get help or find out more below.

Can an opioid overdose be reversed?

Yes—many opioid overdoses can be reversed with treatment. The opioid reversal medications naloxone (also called Narcan®) and naltrexone (also called Revia® or Vivitrol®) can be delivered via a nasal spray or injection, or intravenously (injected into a vein). 

How quickly does the antidote work?

This depends on several factors, including how the reversal drug is delivered. When it is given intravenously in the hospital, naloxone begins reversing an opioid overdose within about two minutes (other methods may take a few minutes longer). Naloxone displaces the opioid in the brain, and can immediately reverse the potentially lethal effects of the opioid on the brain, lungs, and heart.

How long does antidote treatment take?

The treatment may take several hours or longer. Naloxone treatment varies in how long it lasts; the effects may last 20–90 minutes. The effects of opioids last much longer than this, and vary according to the type of opioid. Typically, many doses of naloxone are needed to sustain the reversal until the person is out of danger. This is why professional medical care is so important. 

Where can opioid antidote treatment be accessed?

Naloxone treatment can be accessed in several ways:

  • At hospital emergency rooms
  • Via police departments and paramedics (ambulance responders), after calling 911
  • Via some fire departments
  • In most states, via some trained laypeople (not medical professionals) who may have a history of opioid abuse or family members who are abusing opioids
  • Purchased without a prescription at some Walgreens and CVS pharmacies in some states, though accessibility varies widely. If you or someone you know is dealing with opioid addiction, having naloxone (often known by its brand name, Narcan®) on hand could save their life.

Here’s a map where you can find the laws about accessing naloxone in your state. 

Could I be at risk for opioid abuse?

  • Opioid addiction is difficult to treat; avoiding abuse and addiction is the safest strategy.
  • If you are using an opioid prescription medication, be self-aware about your reasons: Opioid medications are prescribed for long-term pain associated with serious illnesses and conditions or for short-term pain control after surgery or an injury. If you are using opioids for other reasons—e.g., to get high or buzzed—seek help.
  • If you are using opioids for pain relief, and your pain is becoming more difficult to control, discuss that with your doctor immediately.
  • If you are abusing opioids or may be addicted, you will need support with your recovery. 

Where can I get help with opioid abuse or addiction?

Look for programs and specialists who work specifically with teens—research shows these are the most effective. Ask your parent for help in finding a treatment program. You can also:

  • Call this confidential 24/7 helpline: 1-800-662-HELP (4357).
  • Use this free search tool from the Substance Abuse and Mental Health Services Administration to find programs near you.
  • Ask your doctor or other health care provider for a referral to an addiction specialist.
  • Ask at your school nurse’s office, counseling center, church, or community center about finding help for addiction.
  • Call your local hospital for help finding medical professionals with addiction expertise.
  • Ask your parent to check the insurance company website for addiction specialists covered by your plan.
  • Look at community directories or online for programs and specialists in your area. Make sure the person or program is licensed and/or certified in mental or behavioral health. Counseling that includes motivational interviewing and/or functional family therapy (which involves other family members in the counseling session) has been shown to be effective.
  • Go to a detox center. Many offer a free initial consultation.

This survey should take about 5 minutes to complete. You will be prompted to enter your name and email so that we can contact you if you're the winner of this month's drawing.

Your data will never be shared or sold to outside parties. View our privacy policy.

I read the article + learned from it
I read the article + learned nothing
I didn't read the article
What was the most interesting thing you read in this article?

Next >>

Article sources

Margie Skeer, ScD, MPH, MSW, associate professor of Public Health and Community Medicine at Tufts University School of Medicine, adolescent substance use prevention researcher, Boston, Massachusetts.

Achilefu, A., Joshi, K., Meier, M., and McCarthy, L. H. (2017). Yoga and other meditative movement therapies to reduce chronic pain. Journal of the Oklahoma State Medical Association, 110(1), 14–16.

Arnold, R. (2017). Fast Facts and Concepts #83. Why patients do not take their opioids. Palliative Care Network of Wisconsin. Retrieved from https://www.mypcnow.org/blank-aw14v

Back, S. E., Payne, R. L., Wahlquist, A. H., Carter, R. E., et al. (2011). Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. American Journal of Drug and Alcohol Abuse, 37(5), 313–323.

Benson, H. (2016, January 15). For teenagers, adult-sized opioid addiction treatment doesn’t fit. NPR. Retrieved from http://www.npr.org/sections/health-shots/2016/01/15/463046372/for-teenagers-adult-sized-opioid-addiction-treatment-doesnt-fit

Brooner, R. K., King, V. L., and Kidorf, M. (1997). Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. JAMA Psychiatry, 54(1), 71–80.

Califano, J. A. (2014). How to raise a drug-free kid: The straight dope for parents. New York, New York: Simon and Schuster.

Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51).

Centers for Disease Control and Prevention. (2012). Grand Rounds: Prescription drug overdoses—A US epidemic. Morbidity and Mortality Weekly Report, 61(1), 10–13.

Centers for Disease Control and Prevention. (2015). Today’s heroin epidemic infographics. Retrieved from https://www.cdc.gov/vitalsigns/heroin/infographic.html

Centers for Disease Control and Prevention. (2016). Increases in drug and opioid overdose deaths—United States, 2000–2014. Morbidity and Mortality Weekly Report, 64(50), 1378–82.

Centers for Disease Control and Prevention. (2016, December 14). Opioid drugs. Retrieved from https://www.cdc.gov/drugoverdose/opioids/index.html

Centers for Disease Control and Prevention. (2016). Prescription opioid overdose data. Retrieved from https://www.cdc.gov/drugoverdose/data/overdose.html

Centers for Disease Control and Prevention. (2017, February 9). Today’s heroin epidemic. Retrieved from https://www.cdc.gov/drugoverdose/opioids/heroin.html

Centers for Disease Control and Prevention. (2016, December 16). Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html

Centers for Disease Control and Prevention. (2016). Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics.

Centers for Disease Control and Prevention. (2017). Heroin overdose data. Retrieved from https://www.cdc.gov/drugoverdose/data/heroin.html

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry, 71(7), 821–826.

Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Understanding the relationship between prescription opioid and heroin abuse. New England Journal of Medicine, 374, 154–163. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMra1508490#t=article

Coomber, R., & Sutton, C. (2006). Harm Reduction Digest 34: How quick to heroin dependence? Drug and Alcohol Review, 25(5), 463–471. Retrieved from http://onlinelibrary.wiley.com/doi/10.1080/09595230600883347/abstract

Dattani, S. (2017, February 27). Have a life-saving talk with your teen about opioids like fentanyl. Huff Post Parents Canada. Retrieved from http://www.huffingtonpost.ca/shelita/teenagers-opioids_b_14995046.html

Darke, S. (2012). Pathways to heroin dependence: Time to re-appraise self-medication. Addiction, 108(4), 659–667.

Drugs.com. (n.d.). Methadone. Retrieved from https://www.drugs.com/methadone.html

Fortuna, R. J., Robbins, B. W., Caiola, E., Joynt, M., et al. (2010). Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics, 126(6).

Grattan, A., Sullivan, M. D., Saunders, K. W., Campbell, C. I., et al. (2012). Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Annals of Family Medicine, 10(4), 304–311.

Join together staff. (2015, September 24). CVS will sell naloxone without prescription in 14 states. Partnership for Drug-Free Kids. Retrieved from http://drugfree.org/learn/drug-and-alcohol-news/cvs-will-sell-naloxone-without-prescription-14-states/

Jones, C. M., Baldwin, G. T., Manocchio, T., White, J. O., et al. (2016). Trends in methadone distribution for pain treatment, methadone diversion, and overdose deaths—United States, 2002-2014. Morbidity and Mortality Weekly Report, 65(26), 667–671.

Jones, C. M., Paulozzi, L. J., & Mack, K. A. (2014). Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Internal Medicine, 174(5), 802–803.

Lankenau, S. E., Teti, M., Silva, K., Jackson Bloom, J., et al. (2012). Initiation into prescription opioid misuse amongst young injection drug users. International Journal of Drug Policy, 23(1), 37–44.

Miech, R., Johnston, L., O’Malley, P. M., Keyes, K. M., et al. (2015). Prescription opioids in adolescence and future opioid misuse. Pediatrics, 136(5), e1169–e1177.

National Institute on Drug Abuse for Teachers. (2017, February 24). Mind over matter: Prescription pain medications (opioids). Retrieved from https://teens.drugabuse.gov/teachers/mind-over-matter/opioids

National Institute on Drug Abuse for Teens. (2017, March 8). Heroin. Retrieved from https://teens.drugabuse.gov/drug-facts/heroin

National Institute on Drug Abuse. (n.d.). Monitoring the future study: Trends in prevalence of various drugs. Retrieved from https://www.drugabuse.gov/trends-statistics/monitoring-future/monitoring-future-study-trends-in-prevalence-various-drugs

National Institute on Drug Abuse. (2015, November). Prescription and over-the-counter medications. Retrieved from https://www.drugabuse.gov/publications/drugfacts/prescription-over-counter-medications

National Institute on Drug Abuse. (2015). Prescription opioid use is a risk factor for heroin use. Retrieved from https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use

National Institute on Drug Abuse. (2014, January). Principles of adolescent substance use disorder treatment: A research-based guide. Retrieved from https://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-research-based-guide/principles-adolescent-substance-use-disorder-treatment

Noble, M., Treadwell, J. R., Tregear, S. J., Coates, V. H., et al. (2010). Opioids for long-term treatment of noncancer pain. Cochrane. Retrieved from http://www.cochrane.org/CD006605/SYMPT_opioids-long-term-treatment-noncancer-pain

Partnership for Drug-Free Kids. (n.d.). Prevention tips for every age. Retrieved from https://drugfree.org/article/prevention-tips-for-every-age/

Paulozzi, L. J., Budnitz, D, & Xi, Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology of Drug Safety, 15, 618–27.

Popovich, N. (2016, May 25). A deadly crisis: mapping the spread of America’s drug overdose epidemic. The Guardian. Retrieved from https://www.theguardian.com/society/ng-interactive/2016/may/25/opioid-epidemic-overdose-deaths-map

Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. Mortality and Morbidity Weekly Report, 65(50–51), 1445–1452.

Schwartz, A. (2015, April 25). Michael Botticelli is a drug czar who knows addiction firsthand. New York Times. Retrieved from https://www.nytimes.com/2015/04/26/us/michael-botticelli-is-a-drug-czar-who-knows-addiction-firsthand.html?_r=0

Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of national findings, NSDUH Series H-46, HHS Publication No. 13-4795.

Stobbe, M. (2016, December 9). A grim tally soars: More than 50,000 overdose deaths in US. STAT. Retrieved from https://www.statnews.com/2016/12/09/opoid-overdose-deaths-us/

Szalavitz, M. (2016, May 10). Opioid addiction is a huge problem, but pain prescriptions are not the cause. Scientific American. Retrieved from https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/

US Food & Drug Administration. (2017, March 10). Disposal of unused medicines: What you should know. Retrieved from https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm

Utah Department of Health. (2016). Prescription opioid deaths. Retrieved from http://health.utah.gov/vipp/pdf/RxDrugs/PDODeaths2015.pdf

Volkow, N. D. (2014, May 14). America’s addiction to opioids: Heroin and prescription drug abuse. National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

Vowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., et al. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Journal of Pain, 156(4), 569–76.

Walgreens. (2016, December 21). Walgreens expands availability of naloxone without a prescription to 33 states. [News release]. Retrieved from http://news.walgreens.com/press-releases/general-news/walgreens-expands-availability-of-naloxone-without-a-prescription-to-33-states-and-washington-dc.htm

Whalen, J., & Spegele, B. (2016, June 23). The Chinese connection fueling America’s fentanyl crisis. Wall Street Journal. Retrieved from https://www.wsj.com/articles/the-chinese-connection-fueling-americas-fentanyl-crisis-1466618934

White, P. F. (2017, January 30). What are the advantages of non-opioid analgesic techniques in the management of acute and chronic pain? Expert Opinions in Pharmacotherapeutics, 18(4), 329–333.

Whitworth, M. (2015, October 22). Can you really become addicted to a drug after just one hit? Vice. Retrieved from https://www.vice.com/en_us/article/reasons-why-you-cant-get-addicted-to-drugs-after-one-hit

Yokell, M. A., Delgado, M. K., Zaller, N. D., et al. (2014, December). Presentation of prescription and nonprescription opioid overdoses to US Emergency Departments. JAMA Internal Medicine, 174(12), 2034–2037. Retrieved from http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1918924