Opioid Addiction Epidemic Andrew Kolodny MD Chief Medical Officer Phoenix House Foundation New York NY The Opium Poppy Papaver Somniferum 2 Crude Opium Latex on Poppy Head 3 Opioids ID: 493597
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Responding to the Opioid Addiction Epidemic
Andrew Kolodny, M.D.Chief Medical OfficerPhoenix House FoundationNew York, NYSlide2
The Opium PoppyPapaver Somniferum2Slide3
Crude Opium Latex on Poppy Head3Slide4
OpioidsMorphine CodeineThebaineDiacetylmorphine (Heroin)
Hydrocodone (Vicodin)Oxycodone (Oxycontin)Oxymorphone (Opana)
Hydromorphone (
Dilaudid
)
Naturally occurring opioids- also called opiates
Semi-synthetic opioidsSlide5
Prior Opioid Addiction EpidemicsLate 1800s: MorphineMainly middle classFemale > Male Early 1900s: Heroin (pharmaceutical grade)First generation Italians, Jews, Irish
Male > Female1950s-1970s- Heroin (illicit)African American/Latinos Male > FemaleSlide6
6Governor Shumlin devotes entire state of the state speech to Vermont’s opioid addiction epidemicSlide7
Heroin
Cocaine
38,329 drug overdose deaths in 2010
Unintentional Drug Overdose Deaths
United States, 1970–2007
National Vital Statistics System, http://wonder.cdc.gov
YearSlide8
Drug Overdose Deaths by Major Drug Type,United States, 1999–2010CDC, National Center for Health Statistics, National Vital Statistics System,
CDC Wonder. Updated with 2010 mortality data. Slide9
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
11Slide12
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
12Slide13
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
13Slide14
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)
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15Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011Slide16
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Heroin admissions, by age group & race/ethnicity: 2001- 2011Slide17
Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., 1997-2007Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS* 2007 opioid sales figure is preliminary.
Number of DeathsOpioid sales (mg/person)*Slide18
Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010
CDC.
MMWR
2011Slide19
19Slide20
20Slide21
Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and Efforts to Address the Problem.”
Dollars Spent Marketing OxyContin (1996-2001) Slide22
Industry-funded “education” emphasizes:Opioid addiction is rare in pain patients.Physicians are needlessly allowing patients to suffer because of “opiophobia.”Opioids are safe and effective for chronic pain.Opioid therapy can be easily discontinued.
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Industry-funded organizations campaigned for greater use of opioids Pain Patient GroupsProfessional Societies The Joint CommissionThe Federation of State Medical Boards23Slide24
Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;302(2):123
Cited 824 times (Google Scholar)“The risk of addiction is much less than 1%”
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N Engl J Med. 1980 Jan 10;302(2):123.25Slide26Slide27
“
I think that after 20 years of a failed experiment that there are not many people supporting this except for the die-hards and the pharmaceutical industry.” Jane C. Ballantyne, MD FRCAProfessor, Univ. of Washington
Source:
New York Times, April 9, 2012.
“
Tightening the Lid on Pain Prescriptions
”
.Slide28
The Emperor’s New Paradigm:Patient Selection, Risk Stratification & Monitoring28Slide29
Urine Tox Results in Chronic Pain Patients on Opioid TherapySource: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug use in the chronic pain population. Popul Health Manag. 2009;12(4):185–190.29Slide30
Controlling the epidemic:A Three-pronged ApproachPrevent new cases of opioid addiction.Treatment for people who are already addictedSupply control- Medical board & law enforcement efforts to reduce over-prescribing and black-market availability.
30Slide31
Opioid manufacturers continue to advertise opioids as
safe and effective for chronic pain.Slide32
How the opioid industry Frames the ProblemSource: Slide presented by Lynn R. Webster MD at FDA meeting on hydrocodone upscheduling, January 25th, 2013.Slide33
Drug overdose death rates by intent by age group, US, 2008 Slide34
Pain Patients
“
Drug Abusers
”
63% admitted to using opioids for purposes other than pain
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35% met DSM V criteria for addiction
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1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8:573-582.
2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.
This is a
false dichotomy
Aberrant drug use behaviors are common in pain patients
92% of opioid OD decedents were prescribed opioids for chronic pain.
3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.Slide35
Frequently Discussed InterventionsAbuse-deterrent formulationsExpanding access to naloxoneExpanding access to medication assisted treatmentPDMP-based interventionsMandatory prescriber education35Slide36Slide37
Buprenorphine TreatmentPartial agonistWeaker effectsSafer to useLong duration of actionMilder withdrawal symptomsSlide38
Full Opioid AgonistsSlide39
Buprenorphine- A Partial AgonistSlide40
SummaryWe are in the midst of the worst drug epidemic in U.S. history.To end the epidemic we need to:PREVENT new cases of opioid addictionTREAT people who are already addicted40Slide41
www.supportPROP.orgPlease visit
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@
andrewkolodny