There are common signs of a fentanyl overdose: pinpoint pupils, a severely impaired mental state and slow, shallow breathing.
And then there is “wooden chest syndrome.”
During the 2025 Opioids, Pain and Substance Use Disorders (OPSUD) education series, one presenter discussed this rare fentanyl overdose symptom in which rigid chest muscles make breathing difficult.
“Never heard of it. I talked with another attendee who I work with afterwards. She hadn’t heard of it either,” said Amy McKenzie, the clinical director at the behavioral health treatment center Trivium Life Services and a specialist in substance use and trauma. “This shows why we need all of these different experts coming in and presenting, because there’s new things coming out all the time and that’s something we should know.”
Under University of Idaho’s School of Health and Medical Professions, Project ECHO Idaho facilitates the OPSUD series, providing prescribers such as physicians, nurse practitioners and other primary care clinicians with the latest evidence-based science on treating substance use disorders (SUD) and pain. The online series equips Idaho health care workers to confidently prescribe medications for opioid use disorder (MOUD) and treat SUD, even as legislation, drug use trends and treatment recommendations continue to change.
Project ECHO Idaho fills the knowledge gap
Before 2023, prescribers had to complete Drug Enforcement Administration X‑waiver training to prescribe MOUD. Although one in five people with OUD achieve two years of abstinence without medications, those who relapse face a high risk of death, showing the importance of MOUD.
“Part of the reason so few people are getting MOUD is that we still haven’t saturated Idaho’s health care community with the knowledge needed to confidently treat opioid use disorder,” said Dr. Jacob Harris, an addiction medicine specialist at the Boise VA Medical Center and member of the interdisciplinary panel that guides the OPSUD series. “There’s a reticence because of a lack of training, not knowing where to start, and a fear of not doing it correctly.”
Project ECHO Idaho has worked to close this knowledge gap since 2018 through its OPSUD series — its longest running series — and other online SUD series for health care professionals statewide. Many sessions count toward continuing education and professional development. With 264 Idahoans dying from opioid related drug overdoses in 2023, the state’s opioid crisis remains a critical challenge.
They have adapted to the needs of Idaho health care workers, said Shannon McDowell, Project ECHO Idaho program manager. MOUD prescribing requirements have changed over time. Prior to 2023, prescribers were required to complete a special X-waiver training to prescribe MOUD. Now, with eight hours of substance use continuing education a year, prescribers can be licensed to provide any controlled substance, including MOUD. The OPSUD series meets these requirements.
“ECHO used to provide the X-waiver training, but a lot of people across the state were nervous to prescribe so they didn’t go through the training,” McDowell said. “The whole point of changing the requirements was to make sure that there were as few barriers to prescribing MOUD as possible, because it’s a life-saving medication.”
The two primary MOUD are methadone, usually dispensed through opioid treatment programs (OTP), and buprenorphine, which patients can take at home. Because methadone is available only through OTP, usually located in larger cities, buprenorphine has expanded access to lifesaving treatment in rural areas, Harris said.
ECHO has shifted its sessions to cover not only buprenorphine and methadone but also related topics such as mental health counseling, emerging street drug trends and behavioral interventions.
An ever-changing landscape
Although many cases of OUD follow predictable patterns, patients with overlapping factors — such as chronic pain or multiple SUD — often face more complex treatment needs.
For ECHO participants, these complicated cases are a key reason to return. At the end of each session, one participant presents a case study — an unnamed patient they want feedback on from the expert panel and other attendees. The group offers treatment suggestions and guidance on local resources.
“People aren’t a textbook. They’re not black and white,” said Jen Dixon, medication assisted treatment coordinator at the Tristate Clearwater Medical Clinic in Lewiston and longtime OPSUD series participant. “I like to see what’s working for other providers or other specialty areas that really pertain to the client who we’re helping.”
Compounding the situation, Harris ’09, a WWAMI graduate, said the opioid landscape has shifted repeatedly every few years as people moved from prescription opioids to street oxycodone, then heroin and now fentanyl — all drugs in the opioid family. They are often laced with other substances to intensify their effects.
I like to see what’s working for other providers or other specialty areas that really pertain to the client that we’re helping.
Jen Dixon
Medication assisted treatment coordinator at the Tristate Clearwater Medical Clinic
For example, misuse of xylazine — a nonopioid veterinary tranquilizer — emerged in the U.S. in the early 2000s. It slows the heart rate and produces long-lasting euphoria. Kratom, a non-federally regulated drug made from a relative of the coffee plant, can mimic opioid-like sedative and euphoric effects. It has been in Idaho for about a decade.
“I went to my primary care doctor a couple weeks ago and was talking to her about xylazine and she asked, ‘What’s xylazine?’” said McKenzie, who is a panelist on OPSUD and owner of Otterly Resilient Counseling. “I think it’s important for clinicians to know drug trends so they know what’s coming in. Getting that extra knowledge could be critical for patient care.”
Harris notes that kratom and xylazine have been identified in Idaho, although their prevalence waxes and wanes, as all drug trends often do. Old substances can resurface and new ones emerge. To help clinicians stay prepared, ECHO Idaho’s 2025 OPSUD series included how to identify, test for and treat addiction or overdoses involving these drugs.
“People who know the current drug landscape and treatments will fall behind within a year or two if they don’t have a source for current information,” Harris said.
On the behavioral side of treatment, McKenzie said teaching updated therapy protocols and even revised language can help clinicians deliver more effective care.
“If I can vocalize what is going on with me, there’s better understanding and it’s not as scary, right? With the language comes advocacy,” she said. “They can stand up for themselves.”
For Harris, all SUD education comes down to helping Idaho’s communities.
“Treating opioid use disorder saves lives — not only those of people struggling with addiction, but also those who aren’t using,” Harris said.
Over 96% of participants believe the sessions will enhance the care they provide and improve their patients’ health outcomes, according to series feedback. As of 2026, ECHO Idaho continues to discuss both prescriber and behavioral health topics in their Substance Use in Idaho series.