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U.S. Overdose Crisis:
52,404 Deaths in 2015 (33,091 from
Prescription and Illicit Opioids)
National Institute on Drug Abuse
Bringing the full power of science to bear on drug abuse and addiction
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
Science = Solutions
Wilson M. Compton, M.D., M.P.E.
Advancing Addiction Science
Deputy Director
National Institute on Drug Abuse
Marked Geographic and Temporal Variation in Overdose Deaths :
Estimated Age-adjusted Death Rates for Drug Poisoning by County
1999
2015
https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/
Increasing Prenatal Exposure
Admissions for Newborn
Withdrawal Syndromes
(Number per 1000
Admissions)
Source: Tolia VN, Patrick SW, et al. NEJM 2015;372:2118-2126
Science = Solutions
HIV and Hepatitis C Outbreak Linked to
Oxymorphone Injection Use in Indiana, 2015
Peters et al.
New England Journal of Medicine
2016;375:229-239
Overdose Deaths Primarily from Opioids: Prescription
Drugs, Heroin and Synthetics (i.e. Fentanyl and similar)
Any Opioid
Commonly Prescribed Opioids
(natural and semi-synthetic opioids and methadone)
Heroin
Other Synthetic Opioids
(e.g. fentanyl)
ENVIRONMENTAL AVAILABILITY: Current Opioid
Crisis Originated with Prescribing Increases
250
200
Opioid Prescriptions in MILLIONS
Opioid prescriptions
Tripled to MORE THAN 200
MILLION prescriptions in
recent years
150
100
50
0
ECONOMICS: Heroin Increases Due to Lower
Price and Greater Availability
$3,500
"Retail" Price Per Pure Gram
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$-
National Drug Control Strategy--Data Supplement 2014.
https://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ndcs_data_supplement_2014.pdf
Increasing Deaths from Illicitly produced (and
very potent) Synthetic Opioids:
Fentanyl (and related chemicals) Laced-Heroin and
Prescription Pills
ECONOMICS:
CHEAP
Fentanyl
Precursor
Chemicals
Opioid Priority Areas
Advancing the practice of pain management
 Expanded availability and distribution of treatments for
opioid overdoses (i.e. naloxone)
 Expanded access to treatment and recovery services
 Strengthening public health surveillance
 Supporting cutting edge research

Opioid Education
Resources for Medical Students,
Resident Physicians & Faculty
Medical schools have developed innovative curriculum resources about how to identify and
treat patients with substance use disorders
Web training on pain assessment
and treatment
Bringing NIDA
research to
clinical practice
Archived NIDA CME Courses:
Upcoming NIDA CME Course:
Safe Prescribing for Pain
Managing Pain Patients
Who Abuse Rx Drugs
Adolescent Substance Use
(Prescription Opioid Module)
Recent Declines in Opioid Prescriptions
70
60
Opioid MME in BILLIONS
50
40
30
20
10
0
Opioid Morphine Milligram Equivalents
Prescribed Declined 23.1% from
3rd quarter 2010 to 2nd quarter 2016
RESEARCH TARGET:
Safe, Effective Strategies for Pain Management
Knowledge of Pain Pathways –
New Biomarkers for Pain?
New study assess glial role in human pain
• Patients with low back pain (LBP) versus controls
–Uses PET to detect levels of glial protein (TSPO)
–Demonstrates role of glial activation in human pain
–Possible biomarker
–May suggest new treatments for chronic pain
Loggia et al., Brain 2015;138.
Science = Solutions
New Target for Pain Control
• Congenital analgesia: rare condition, individuals cannot feel pain
–Mutation identified in gene that encodes for Nav1.7 – sodium channel
that regulates pain-sensing neurons
• Targeting Nav1.7 to produce analgesia
–Several companies now have drugs in pipeline to block channel
• Targeting complications
–Understanding what happens when Nav1.7 is blocked
Science = Solutions
A Promising New Generation Of Pain Therapeutics:
Biased Mu-Opioid Receptor Ligands
Soergel DG, et al., Pain 2014. Manglik A, et al., Nature 2016. DeWire SM, et al., JPET 2013. Bohn LM, et al., Science 1999
Science = Solutions
Predicting Addiction?
Variant
Common Type
• OPRM1 encodes for the target of
opioids
• Can variants predict likelihood
addiction?
• OPRM1 variant
– Affects receptor levels in brain
–
Associated with increased risk
for addiction, overdose severity
Hancock et al., Biol Psychiatry 2015; 78.
Manini et al., J Med Toxicol 2013; 9.
Peciña et al., Neuropsychopharmacology 2015; 40.
Mapping the differences
Direct Overdose Intervention
Naloxone Distribution for opioid overdose victims.
The potential for direct intervention to save lives.
 “Evzio” naloxone auto-injector
APPROVED BY FDA,
April 3, 2014
 “Narcan Nasal Spray” naloxone
APPROVED BY FDA,
November 18, 2015
Science = Solutions
Retail Pharmacy Prescriptions for
Naloxone Increase Markedly
2016
25000
20000
15000
2015
2014
10000
5000
Sources: Jones CM, Lurie PG, Compton WM. Am J Public Health. 2016;106(4):689-690; IMS Health, published
https://www.performance.gov/content/reduce-opioid-related-morbidity-and-mortality
2Q2016
1Q2016
4Q2015
3Q2015
2Q2015
1Q2015
4Q2014
3Q2014
2Q2014
1Q2014
4Q2013
3Q2013
2Q2013
1Q2013
4Q2012
3Q2012
2Q2012
1Q2012
4Q2011
3Q2011
2Q2011
1Q2011
4Q2010
3Q2010
0
2Q2010
• Outpatient prescribing
of naloxone may
complement
community-based
distribution and first
responder access.
30000
1Q2010
• Retail prescriptions
show an increase of
9520% from the 4th
quarter of 2013 to 2nd
quarter 2016.
35000
Science = Solutions
Overdose Treatment Research: Saving Lives for
Future Recovery
•
•
•
•
New stronger, longer acting formulations to
address more potent opioids (e.g. fentanyl)
Stimulation devices to prevent respiratory
depression
Overdose detection and alert technologies
Post-overdose interventions to ensure
engagement in treatment
Medications Are Effective
Medication Assisted Treatment
(MAT) DECREASES:
• Opioid use
• Opioid-related overdose deaths
• Criminal activity
• Infectious disease transmission
And INCREASES
• Social functioning
• Retention in treatment
Kakko J et al., The Lancet 2003.
Medications are Underused
In 48 states and D.C., Opioid Abuse
and Dependence Rates Exceed
Buprenorphine Treatment Capacity
In 2014, only 25% of opioid
admissions had treatment
plans that included receiving
medications.
75%
25%
Jones C et al., Am J Public Health 2015.
MAT
No MAT
Treatment Episode Data Set (TEDS): 2004-2014.
Science Driven Solutions: Improving Addiction Treatment
Recent Advances:
Advancing Addiction Science
• Probuphine: buprenorphine implant; releases sustained dose for up to 6
months (FDA Approval May 26, 2016)
• Initiating buprenorphine treatment in the emergency department improves
treatment engagement and reduces illicit opioid use
• Extended release naltrexone initiated in criminal justice settings lowers
relapse rates and overdoses
Lee JD, et al., Addiction 2015;100:1005-1014
and New Eng J Med 2016;374:1232-1242
Non-Pharmacological Treatments for Addiction
Transcranial Magnetic
Stimulation (TMS)
Transcranial Direct
Current Simulation (tDCS)
Salling and Martinez, 2016.
Deep Brain Stimulation (DBS)
Implanted electrodes emit electrical
stimulation to targeted brain region
NIH Opioid Research Initiative
Using Research to End the Opioid Crisis
PAIN MANAGEMENT
Safe, effective, non-addictive strategies
OPIOID
ADDICTION
TREATMENT
New, innovative
medications and
technologies
Nonpharmacological
Treatments (e.g. TMS)
Opioid Vaccines
Biomarkers
For Pain
Non-Opioid
Analgesics
Respiratory
Stimulation
Devices
OVERDOSE
REVERSAL
Interventions to
reduce mortality
and link to
treatment
Science = Solutions : Using Research to Improve
HIV and Hepatitis C in Rural Areas
NIH is partnering with the CDC, SAMHSA and the
Appalachian Regional Commission (ARC) to conduct
research to address increased opioid injection drug use
and resulting overdose, HIV and Hepatitis C infection.
–Improve understanding problem’s scope;
contributing health trends
–Identify resources, obstacles
–Develop intervention approaches to address
these health threats
Science = Solutions : Expanding Medication Assisted
Treatment for Opioid Use Disorders in the Context of SAMHSA
Opioid STR Grants (RFA-DA-18-005)
• 21st Century Cures Act authorized and $500 million appropriated
FY2017 ($500 anticipated FY2018).
• Opportunity for research on expanding MAT for OUD
• FOA solicits rigorous research, in collaboration with Single State
Agencies, on effectiveness of approaches to
– expanding MAT in primary care
– continuity of care for individuals with OUD
– linking individuals treated with naloxone to OUD treatment
• Phased projects: 1 year planning phase (R21), 3 year research
research project phase (R33). $200K/$500K direct maximum.
• Due date June 20, 2017
Science = Solutions
Advancing Addiction Science
www.drugabuse.gov