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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. 2 Opioid? Opiate? Heroin? 3 4 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 5 6 7 Heroin Deaths in Monroe and surrounding counties 8 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. 9 Where Are We? 1. 2. 3. 4. 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 10 Definitions Opioid – refers to ALL opiates, natural, synthetic, and semi-synthetic Opiate – drugs derived from opium Opium – the dried latex harvested from Papaver somniferum 11 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 12 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 13 It’s not just heroin… 1. 2. 3. 4. 5. 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 14 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. 15 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) 16 17 18 19 1996 20 1996 21 http://www.gao.gov/new.items/d04110.pdf 22 23 The evidence Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;203(2):123 24 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 25 26 http://www.nytimes.com/2016/06/14/health/pain-treatment-er-alternative-opioids.html 27 28 Where Are We Going? 1. Recognition • Discussions in a Public Forum • Opioid-prescribing CME • Residency Curriculum 29 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 30 Continuing Medical Education (CME) http://cme.rwjms.rutgers.edu/images/mainphoto.jpg 31 Resident Education http://2.bp.blogspot.com/-rlZ9Qm2gc-0/TXvVNLvcWNI/AAAAAAAAAvg/mu21ShrlgxM/s1600/phrases.jpg 32 Where Are We Going? 1. Recognition 2. Prevention Decreasing new exposures • Ankle Sprain? • RICE it. • Rib Fractures? • Lidoderm it. • Dental Pain? • Nerve Block it. 33 Now for some Hippie Stuff 34 Prevention Decreasing the supply of prescription medications available • Fewer prescriptions • Shorter duration • Decreased manufacturing • Increased co-pays • Change Prior Authorization policies • Prescription Monitoring Program 35 Prescription Monitoring Program 36 37 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. 38 Where Are We Going? 1. Recognition 2. Prevention 3. Treatment 39 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) 40 https://ncadd-ra.org/news-resources/resources-advocacy-research 41 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 42 43 44 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 45 46