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The Opioid Epidemic:
Where are we, How did we get
here, and Where are we going?
Aaron Fields, MD
Addiction Medicine Fellow
Instructor of Clinical Emergency Medicine
Public Health Grand Rounds
Friday, October 21, 2016
Conflicts of Interest
I’m not being paid for this. None of the interests mentioned pay me.
Eventually I’ll be working for/with some of the community treatment
agencies, I have done my best to present the information in an unbiased
manner.
Ownership or Intellectual Property
None of the images, graphs, or charts contained herein are my original
works, and I do not claim ownership of them. Where possible, I have
cited where they have been graciously borrowed from.
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Opioid? Opiate? Heroin?
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Increases in Drug and Opioid Overdose Deaths
— United States, 2000–2014
“The United States is experiencing an epidemic of drug overdose
(poisoning) deaths… From 2000 to 2014 nearly half a million persons in
the United States have died from drug overdoses. In 2014, there were
approximately one and a half times more drug overdose deaths in the
United States than deaths from motor vehicle crashes (4). Opioids,
primarily prescription pain relievers and heroin, are the main drugs
associated with overdose deaths. In 2014, opioids were involved in 28,647
deaths, or 61% of all drug overdose deaths; the rate of opioid overdoses
has tripled since 2000.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
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Heroin Deaths in
Monroe and
surrounding counties
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Just the numbers – in 2014 – in NY
825 heroin-related overdose deaths
• 159 more than in 2013 (23.9% more)
• Nearly 25x the number in 2004 (33… Think about that)
• Per million people, the heroin death rate went from 1.7 to 41.8
1008 Rx-opioid related overdose deaths
• 0.9% more than 2013
• Nearly 4x the number in 2005
These numbers have only gone up since then.
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Where Are We?
1.
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5.
6.
https://images-na.ssl-images-amazon.com/images/I/51F5ysrF9GL.jpg
http://thumbs3.ebaystatic.com/d/l225/m/mB-cbtBGFVTbRqydBn_FNMw.jpg
https://upload.wikimedia.org/wikipedia/commons/1/1c/Papaver_somniferum_(3).jpg
http://www.nic.funet.fi/pub/sci/bio/life/plants/magnoliophyta/magnoliophytina/magnoliopsida/papaveraceae/papaver/somniferum-1a.jpg
https://www.strictlymedicinalseeds.com/images/products/Turkish_poppy_300.jpg
http://previews.123rf.com/images/rmorijn/rmorijn1406/rmorijn140600125/29580023-Dutch-landscape-with-many-pink-flowers-en-seedboxes-of-Papaver-somniferum-plants-and-in-the-backgro-Stock-Photo.jpg
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Definitions
Opioid – refers to ALL opiates, natural,
synthetic, and semi-synthetic
Opiate – drugs derived from opium
Opium – the dried latex harvested from
Papaver somniferum
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Heroin
Diacetylmorphine
• Extensive 1st pass metabolism to morphine
• 2-4x potency of morphine when used IV
• Acetyl groups allow blood-brain barrier crossing
• Active prodrug
https://en.wikipedia.org/wiki/Heroin
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1.
2.
3.
4.
5.
6.
http://media.nj.com/centraljersey_impact/photo/heroin-packets3jpg-9e831231c48cb1a0.jpg
http://extras.mnginteractive.com/live/media/site101/2016/0326/20160326__p_EAG-L-VTHEROIN~1_500.jpg
https://upload.wikimedia.org/wikipedia/en/6/65/Chunkyno3.jpg
http://all-len-all.com/wp-content/uploads/2015/08/heroin-rock.jpg
https://upload.wikimedia.org/wikipedia/commons/5/5b/Heroin_asian.jpg
https://s-media-cache-ak0.pinimg.com/originals/d9/57/be/d957be8f26dc615251fbec7a805afc5b.jpg
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It’s not just heroin…
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6.
http://images.addictionblog.org/cherrycake/wp-content/uploads/2012/10/Tolerance-to-OxyContin2.jpg
http://www.addictionhelpline.com/img/percocet.jpg
http://thestockmasters.com/files/images/story-images/vicodin.png
https://www.drugs.com/drp/images/pills/p05303b3.jpg
http://img1.exportersindia.com/product_images/bc-full/dir_84/2517192/roxicodone-30mg-972834.jpg
https://dailymed.nlm.nih.gov/dailymed/archives/image.cfm?archiveid=224052&name=bdebf90a-74f9-44fa-b37e-3ea41d9caba9-03.jpg
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http://www.cdc.gov/drugoverdose/data/prescribing.html
Centers for Disease Control and Prevention. Vital Signs: Variation Among States in Prescribing of Opioid Pain
Relievers and Benzodiazepines — United States, 2012. MMWR 2014; 63(26):563-568.
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This 2014 heat graph provided by the Centers for Disease Control and Prevention, displays heroin overdose deaths per population of 100,000 across the
United States. Dark blue indicates numbers of four and below, and as numbers increase, they turn to a dark red, indicating closer to 20 and over deaths
per 100,000. (CDC Graph photo)
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1996
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1996
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http://www.gao.gov/new.items/d04110.pdf
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The evidence
Porter J, Jick H. Addiction
rare in patients treated with
narcotics. N Engl J Med.
1980 Jan 10;203(2):123
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The evidence
Portenoy RK, Foley KM.
Chronic use of opioid
analgesics in non-malignant
pain: report of 38 cases.
Pain. 1986 May;25(2):17186
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http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html
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Where Are We Going?
1. Recognition
• Discussions in a Public Forum
• Opioid-prescribing CME
• Residency Curriculum
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Discussion in a Public Forum
1. http://oshercenter.org/wp-content/uploads/sites/2/2015/02/photo-eakens-300x206.jpg
2. http://onlineathens.com/sites/default/files/imagecache/full/12535557.jpg
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Continuing Medical Education (CME)
http://cme.rwjms.rutgers.edu/images/mainphoto.jpg
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Resident Education
http://2.bp.blogspot.com/-rlZ9Qm2gc-0/TXvVNLvcWNI/AAAAAAAAAvg/mu21ShrlgxM/s1600/phrases.jpg
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Where Are We Going?
1. Recognition
2. Prevention
Decreasing new exposures
• Ankle Sprain?
• RICE it.
• Rib Fractures?
• Lidoderm it.
• Dental Pain?
• Nerve Block it.
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Now for some Hippie Stuff
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Prevention
Decreasing the supply of prescription medications available
• Fewer prescriptions
• Shorter duration
• Decreased manufacturing
• Increased co-pays
• Change Prior Authorization policies
• Prescription Monitoring Program
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Prescription Monitoring Program
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The Comprehensive Addiction and Recovery Act
(CARA)
July 22, 2016
Expanded Naloxone availability
Improving Prescription Drug Monitoring Programs
Increasing prevalence of Drug Court programs
Increase funding for Addiction Treatment (MAT)
Enable those with past drug problems to qualify for federal student aid
programs
Training vets with military emergency medical training to meet
requirements for becoming civilian healthcare professionals.
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Where Are We Going?
1. Recognition
2. Prevention
3. Treatment
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Addiction Treatment Programs
Outpatient – ABC, Baden St., Restart, Conifer, Delphi, Huther-Doyle,
RGH, Unity, Sisters Hospital Rochester Pathways, Strong Recovery, Villa of
Hope, Westfall Associates
Residential – Restart, East House, Pathway Houses of SBH, Unity,
Veterans, Villa of Hope, YWCA Supportive Living
Inpatient – Norris, Unity, Confier
Detox – Syracuse Behavioral Health (IN ROCHESTER)
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https://ncadd-ra.org/news-resources/resources-advocacy-research
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Medication Assisted Treatment
Methadone
• Full agonist, very long half-life
• Daily dispensing
Buprenorphine
• Partial agonist/antagonist, very long half-life
• Often start with weekly prescription
Naloxone
• Antagonist, short half-life, NOT a controlled substance
• Available in monthly intramuscular injection - Vivitrol
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References
1. Beno, JM. Heroin/fentanyl deaths investigated by the Monroe County Medical Examiner’s Office in 2015. Office of the Medical Examiner, Forensic
Toxicology Laboratory. 2/22/2016, updated 3/4/2016.
2. http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
3. Olson, Kent R. Poisoning & Drug Overdose. 2012. The McGraw-Hill Companies.
4. Provenzano DA, Viscusi ER. Rethinking the role of opioids in the outpatient management of chronic nonmalignant pain. Curr Med Res Opin.
2014;30(10):051-2062. http://dx.doi.org/10.1185/03007995.2014.921610. doi: 10.1185/03007995.2014.921610.
5. “S. 524 — 114th Congress: Comprehensive Addiction and Recovery Act of 2016.” www.GovTrack.us. 2015. October 17, 2016 https://www.govtrack.us/congress/bills/114/s524
6. Kolodny, A. “The Opioid Addiction Epidemic: How marketing and regulatory failure led to a public health crisis.” Phoenix House. Accessed online
10/16/2016 at http://www.pharmedout.org/pdf/R3DSlides/Kolodny.pdf
7. https://ncadd-ra.org/wp-content/uploads/2013/05/MC-OASAS-Certified-Treatment-Provider-Referral-Template-August-2016.pdf
8. https://www.naatp.org/resources/clinical/comprehensive-addiction-and-recovery-act
9. http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
10. http://www.cdc.gov/vitalsigns/heroin/
11. http://www.medscape.com/viewarticle/846636
12. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. CDC MMWR. 1 Jan 2016;
64(50);1378-82. Accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm on 10/20/2016
13. https://www.dea.gov/divisions/hq/2016/hq100416.shtml
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