AMERICA S OPIOID CRISIS

Transcription

1 AMERICA S OPIOID CRISIS Impact on Nuclear Safety/Security Johnny Rogers, Manager Access/FFD TVA, SAE, MA Addictions Dr. Brenda Sowter, MRO TVA, SAE 1

2 OBJECTIVES Understand what are opioids and where do they exert their actions Understand how and where did the opioid crisis begin and the pattern in the rise of opioid deaths Understand the different types of opioids and their risk factors for abuse Understand the US Government s five point Opioid Strategy with its five priorities to combat the crisis Understand how an opioid overdose presents and treatment options Understand the spectrum of tolerance to addiction Consider challenges this crisis presents to the MRO, SAE, and the Nuclear Industry. 2

3 THE OPIOID CRISIS Drug overdoses are the leading cause of death for Americans under 50, and deaths are rising faster than ever, primarily because of opioids The number of overdose deaths reached 52,404 people in 2015 or the equivalent of about 145 Americans every day and 64,000 people in 2016 more people than the Vietnam War. Deaths from drug overdoses jumped in nearly every county across the United States, driven largely by an explosion in addiction to prescription painkillers and heroin. In 2015, roughly 2 percent of deaths 1 in 50 in the United States were drug related. Some of the largest concentrations of overdose deaths were in Appalachia and the Southwest according to the Centers for Disease Control and Prevention. 3

4 OVERDOSE DEATHS ACROSS THE UNITED STATES FROM 1999 TO

5 OPIOID OVERDOSE DEATH FROM According to the CDC, from , more than 350,000 people died from an overdose involving any opioid, including prescription and illicit opioids. The rise in opioid overdose deaths can be outlined in three distinct waves. 1. The first wave began with increased prescribing of opioids in the 1990 s with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least The second wave began in 2010, with rapid increases in overdose deaths involving heroin. 3. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids particularly those involving illicitly-manufactured fentanyl (IMF). The illicitly-manufactured fentanyl market continues to change and IMF can be found in combination with heroin, counterfeit pills, and cocaine. 5

6 THREE WAVES OF OPIOID DEATHS 6

7 SOME STAGGERING STATISTICS Nearly 80% of heroin users reported misusing prescription opioids prior to heroin use. 116 PEOPLE A DAY DIE FROM OPIOID OVERDOSE About 66 % of the more than 64,000 drug overdose deaths in 2016 involved a opioid 40 % involved a prescription opioid. Prescription drug misuse is second only to marijuana use as the nation s most commonly used illicit drug. PAY ATTENTION: The prevalence of non-medical use of psychotherapeutic drugs (pain relievers, stimulants, sedatives and tranquilizers) among adults is higher than use of ALL illicit drugs (e.g. cocaine, methamphetamine, heroin, etc.) except marijuana! According to the 2015 National Survey on Drug Use and Health (NSDUH), ~91.8 million adults (aged 18 or older) were past year users of prescription pain relievers in 2015 more than 1/3 of the adult population. 7

8 OTHER DRUG STATISTICS About 11.5 million adults (63.4%) misused prescription pain relievers at least once in the past year with the most common reason of relieving physical pain About 5.7 million adults misused prescription tranquilizers at least once in the past year with the most common reasons to relax or relieve tension. About 4.8 million adults misused prescription stimulants at least once in the past year with the most common reason for misuse to help be alert or stay awake, help concentrate, and to help study. About 1.4 million adults misused prescription sedatives at least once in the past year with the most common reason to help with sleep. 8

9 PRESCIPTION OPIOID RISK FACTORS 9

10 HEROIN RISK FACTORS 10

11 FENTANYL RISK FACTORS 11

12 WHO IS TO BLAME? Drug companies and doctors have been accused of fueling the opioid epidemic but many entities have played a role in getting America to this point! In the1990 s, the American Medical Association declared physicians were not adequately treating pain. Pain was considered the fifth vital sign, giving pain equal status with blood pressure, heart rate, respiratory rate, and temperature. The Joint Commission, a non-profit organization that accredits hospitals and US healthcare organizations, set pain management standards high by stating in their standards Pain is assessed in all patients. Of course, their website denies contributing to the current prescription opioid epidemic. Insurers limit access to pain medications that carry a lower risk of addiction or dependence providing easier access to generic opioids due to opioid drugs are generally cheap while safer alternatives are often more expensive. Lidocaine patches that are safe and not addictive require a prior authorization from most insurers. Conversely, most insurers cover common opioids with very few requiring prior authorizations a labor-intensive effort for doctors offices. 12

13 AND THE BLAME GAME CONTINUES: The U.S. Department of Health and Human Services states: In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relieves and healthcare providers began to prescribe them at greater rates. The truth of the matter is: Everyone has a stake in the blame, including the patient himself! When a naive patient is prescribed narcotic pain relievers, the vast majority of prescriptions are for a prn (as needed) basis when the pain is increased; but we do not think as patients we should experience any pain at all and increase our intake. This mindset leads to tolerance which leads to increased dosing, which if left unchecked, can lead to abuse or addiction. Very few purposely set out to be an addict! Beware of articles on this topic! Carefully scrutinize who is behind the statements as the alliance of the organization or individual(s) will reflect the position of their statements. 13

14 Impact on the Workforce The national opiate epidemic has found its way into the workplace. According to Bloomberg magazine, about two-thirds of those who report misusing pain-relievers are on the payroll. Bloomberg reports that workers are disappearing from the workforce at an alarming rate. Skilled workers are already a commodity, but the opiate epidemic is further adversely affecting staffing. Fifty seven percent of employers say they perform drug tests according to the National Safety Council. Out of those, more than 40 percent don t screen for synthetic opioids like oxycodone. Why? Workers are needed. 14

15 Impact on the Workforce The National Safety Council: 29 percent of employers reported impaired job performance due to prescriptionpainkiller use, 15 percent cited an injury or near miss that attributed to the drugs. As many as 70 percent said their workforce had been affected in some way. Last year alone, the number of workers who died at work because of drug- or alcohol-abuse-related incidents increased by more than 30 percent, to more than 200. Five years ago, fewer than 70 people died from overdoses at work Since 2012, the number of people dying from drug or alcohol related causes while on the job has been growing by at least 25 percent each year, according to the Bureau of Labor Statistics. 15

16 A Question of Impairment The research and empirical data is compelling. The percentage of fatally injured drivers who tested positive for prescription opioids rose sevenfold from 1 percent in 1995 to over 7 percent in 2015, according to a study conducted by Columbia University s Mailman School of Public Health. Dr. Li stated, The opioid epidemic has been defined primarily by the counts of overdose fatalities. Our study suggests that increases in opioid consumption may carry adverse health consequences far beyond overdose morbidity and mortality. Translation: As bad as you think it is, it is much worse. 16

17 Why Is This Happening? Two words: Pain and Pleasure Pain Inaba & Cohen adds: Physicians prescribe opiates to deaden pain, control coughing, stop diarrhea. People self prescribe opioids to drown emotional pain, get a rush, induce euphoria, prevent withdrawal symptoms. Humans have internal opioids (endorphins, enkephalins, and dynorphins) natural pain killers. Opioids are effective because they act like the body s internal painkillers (endorphines) Two primary effects of both internal and external opioids are on pain and pleasure. 17

18 Why Is This Happening? Pain Pain signals damage, transmitted from nerve cell to nerve cell by a neurotransmitter called: Substance P, a neuropeptide small protein-like molecules used by neurons to communicate with each other. Opioid drugs are effective because they act like the body s internal pain killers. Opioids (internal and external) limit the release of Substance P and help block what little does get through to the receiving neurons. Pain control is not limited to physical pain (Opiates Decrease anxiety, detachment, drowsiness, deadening of unwanted emotions) 18

19 Why Is This Happening? Pleasure Inaba & Cohen state that the other major effect of opioids involves endorphins and dopamine. The reward pathway in the brain (includes the nucleus accumbens) When this system functions normally, it positively reinforces actions good for the body s survival. (eating, having sex, etc) Brain is reminded (unconsciously) of the actions that feel good and bring pleasure, so that these actions can be replicated for the purpose of sustaining human life. 19

20 Why Is This Happening? When the natural internal endorphins and enkephalins give a surge of pleasure, various cells in the brain monitor the action and when the need is filled, a cut signal announces: you can stop now. Powerful psychoactive drugs like heroin disrupt the stop switch. The brain becomes unable to stop the activity. The more often the circuit is overloaded by heroin or other powerful opiates, the greater the switch malfunction. The same area of the brain that signals pleasure/reward also signals alleviation of pain. So when people want to either induce a good feeling/rush/high OR alleviate emotional/mental/[physical pain, they sometimes reach for an opioid. The feeling of rush/high is replaced with relief from withdrawal Pleasure pain principle is reversed. 20

21 Why Is This Happening? When opioids are used, both the rush and pain alleviation are interpreted as good for the body, thus worth repeating. The brain rewires (remembers) and imprints this as new code. Drug abusers will keep using past the point of pain relief, searching for an emotional high, or because they are unable to stop. Non-abusers are usually able to stop when pain is relieved. 21

22 A Question of Impairment According to Kuhn, Swartzwelder, Wilson (2014) new research has shown that the brains of regular opiate users don t work normally. Long term users have trouble with complex decision making Make poor choices, and have some trouble learning new information. Although opiates are not particularly toxic to neurons (unlike alcohol) repeated suppression of breathing that is cause by continuous opiate use can produce changes in the brain associated with hypoxia (low blood oxygen). Long time abusers simply don t breath enough to maintain normal levels of blood oxygen. Long term consequences could include impaired cognitive functioning. 22

23 A Question of Impairment So, if prescription opiates are impairing, what should be done with those who are engaged in drug treatment, Suboxone, Buprenorphine is the generic term. Subutex contains buprenorphine only while Suboxone contains both buprenorphine and naloxone, One view is that freedom from all drugs is the only real recovery. Still others believe pharmacology is safe and provides stability and functionality to the addicted. Difficult to not to embrace special opioids that tame the cravings and ward off the misery of withdrawal sickness. Has quickly become one of the biggest-selling drugs in the U.S. In Tennessee, prescriptions have doubled in the last five years. 23

24 Effects of Suboxone Suboxone acts as a depressant in the body The short-term, desirable effects of Suboxone include: A pain relieving effect that is between 20 and 30 times more powerful than morphine. A mild euphoria that can lasts for around 8 hours with general effects of the substance lasting for hours. A sense of calm and inflated well-being. A perception of fewer worries and lower stress. Increased relaxation. Ideally, limit the withdrawal symptoms and decrease the frequency and intensity of cravings in the person addicted to opiates, making it a safer alternative 24

25 Effects of Suboxone As with other drugs of abuse, taking too much Suboxone in the short-term can lead to unwanted effects including: Sleepiness. Confusion. Nausea. Respiratory depression. The drug itself can lead to tolerance and dependence Suboxone does have a Dark Side 25

26 Effects of Suboxone DIVERSION 26

27 Effects of Suboxone The pills are often sold on the street Very popular street drug Suboxone can be sold on the street to finance their addiction Additionally, Suboxone produces a very steady high without the high risk of overdose 27

28 A PUBLIC HEALTH EMERGENCY In 2017, HHS declared a public health emergency after President Trump directed executive agencies use all appropriate emergency authorities and other relevant authorities to combat this national crisis. Under President Trump, in April 2017, HHS unveiled a new five point Opioid Strategy with five priorities: 1. Improve access to prevention, treatment, and recovery support services 2. Target the availability and distribution of overdose-reversing drugs 3. Strengthen public health data, reporting, and collection 4. Support cutting-edge research on addiction and pain 5. Advance the practice of pain management 28

29 WHAT TO DO AS AN ACCESS/FFD PROGRAM MANAGER? When determining medication safety profile, our current drug testing program does not guide us on the path. Given the knowledge gleamed from America s Opioid Crisis, it is clear that a valid prescription is no longer reason to assume all is well. Items to consider: The half life of the drug Should the dosing be restricted exclude before or during shift hours? How long before shift begins should the drug be allowed to be taken? Should only opioid medication have consideration? There is a five hour rule in place to address alcohol consumption. Are opiates less impairing than alcohol? 29

30 THE ACOEM The American College of Occupational and Environmental Medicine (ACOEM) Evidence-based Practice Opioids Panel recommends preclusion of opioid use in safety-sensitive jobs. In the ACOEM Practice Guidelines: OPIOIDS AND SAFETY-SENSITIVE WORK, OF JULY 2014: The guideline extends the above recommendation beyond operation of motor vehicles to include other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation, work with sharps, work with risk of injury (e.g., heights) and tasks involving high levels of cognitive function. The ACOEM Practice Guideline further states it did not find either absence of or lower risk among those on either lower doses or weaker opioids, suggesting if there is a threshold for no increased risk, that threshold is apparently at a very low morphine equivalent dosage. 30

31 FURTHER PITFALLS FOR THE NUCLEAR INDUSTRY We will see more individuals going on Suboxone for opioid addiction/treatment and are the individuals declaring the medication? Pitfalls to consider for the nuclear industry: a. Given the known effects of opioids (consider tolerance and dependence), do we want individuals inside the PA on Suboxone? b. Since there is not a specific no fly medication list generated or backed by the NRC, the liability falls on the licensee, MRO, SAE. c. How do we justify the use when an injury occurs? d. Is our BOP system robust enough to capture aberrant behavior, given dependence? (Aberrant behaviors can be hard detect with high tolerance.) e. Are licensees willing to accept Suboxone as a chronic, long-term treatment? What about Methadone?

32 Thank You 32