Evolution of the Opioid Epidemic
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1 Clinical Directors Network, Inc. (CDN) Evolution of the Opioid Epidemic February 5, :30 PM-4:00 PM EST Richard C. Dart, MD, PhD Director, Rocky Mountain Poison and Drug Center, Denver Health Professor, University of Colorado Health Sciences Center
2 Competing Interest Statement History 2002, launched by Purdue Pharma L.P. 2006, independent ownership by Denver Health and Hospital Authority Denver Public Hospital for 150 years State sanctioned independent authority Conflict of Interest Statement Many manufacturers of prescription opioids or stimulants as well as federal agencies subscribe to RADARS System. RADARS System is the property of Denver Health and Hospital Authority, a political subdivision of the State of Colorado. Subscribers receive information, but do not participate in developing the System, data collection, or analysis of the data. They do not have access to the raw data. Employees are prohibited from personal financial relationships with any company. 2
3 Mosaic Surveillance of Prescription Drug Abuse Acute Health Events Poison Center Program Non-Medical Use Survey of Non- Medical Use of Prescription Drugs (NMURx) Entering Treatment Survey of Key Informants Patients Drug Transactions Drug Diversion Program StreetRx.com Entering Treatment Opioid Treatment Program Illicit Market Price StreetRx Program Advanced Users/Targeted Investigations Researcher & Patients Interacting Directly (RAPID) Internet Chatter Web Monitoring Program 3
4 Prescription opioid abuse is at record highs and increasing
5 Prescription opioid abuse is at record highs and increasing
6
7 One Problem?
8 One Problem?
9 Peak Rx Drug Abuse Deaths 9
10 The problem is Apple! Peak Rx Drug Abuse Deaths 10
11 The problem is Apple! Peak Rx Drug Abuse Deaths 11
12 Prescription Opioid Abuse Decreasing in US Poison Centers Drug Diversion Substance Abuse Treatment Centers Trends in Opioid Analgesic Abuse and Mortality in the United States. N Engl J Med 2015;372:
13 Prescription Opioid Abuse by Active Pharmaceutical Ingredient RADARS Poison Center Program Intentional Abuse Exposures Per 100,000 population 13
14 Prescription Opioid Abuse by Active Pharmaceutical Ingredient RADARS Poison Center Program Intentional Abuse Exposures Per 100,000 population Methadone 14
15 Prescription Opioid Abuse by Active Pharmaceutical Ingredient RADARS Poison Center Program Intentional Abuse Exposures Per 100,000 population Methadone Buprenorphine 15
16 Petty died at 66 of "multisystem organ failure due to resuscitated cardiopulmonary arrest due to mixed drug toxicity: fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetylfentanyl, and despropionyl fentanyl."
17 What is the Problem We Need to Solve? Person in Pain Filling the Balloon Susceptible Person Intact Chewed Crushed Outcomes Addiction Recreational Abuser Overdose Abuse of Other Drugs Death 17
18 Prescription Drug Abuse Opioid and Other Opioids with abuse deterrent properties (ADOs / ADFs) Public Health and Heroin The Rise of other Rx drugs abuse
19 Potential Effects of Interventions Person in Pain Emptying the Balloon Outcomes Susceptible Person Intact Chewed Crushed OUD Recreational Abuser OD Abuse of Other Drugs Dth 19
20 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement P D M P Intact Chewed Crushed Outcomes OUD Recreational Abuser OD Abuse of Other Drugs Dth 20
21 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement P D M P Intact A D F Chewed Crushed Outcomes OUD Recreational Abuser OD Abuse of Other Drugs Dth 21
22 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement Recreational Abuser P D M P Intact A D F Chewed A D F A D F Crushed Outcomes OUD OD Abuse of Other Drugs A D F Dth 22
23 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement Recreational Abuser P D M P Intact A D F Chewed A D F A D F Crushed Outcomes OUD OD Abuse of Other Drugs A D F Dth 23
24 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement Recreational Abuser P D M P Intact A D F Chewed A D F A D F Crushed Outcomes OUD OD Abuse of Other Drugs Heroin A D F Dth 24
25 Potential Effects of Interventions Emptying the Balloon Person in Pain Guidelines Susceptible Person Enforcement Recreational Abuser P D M P Intact A D F Chewed A D F A D F Crushed Outcomes OUD OD Abuse of Other Drugs Heroin A D F Dth Treat 25
26 10 FDA-approved ADFs: All physical/chemical or agonist/antagonist Product Drug Substance Sponsor Approval Marketed Oxycontin oxycodone Purdue 4/4/2010 YES Targiniq ER oxycodone + naloxone Purdue 7/23/2014 NO Embeda morphine + naltrexone Pfizer 10/17/2014 YES Hysingla ER hydrocodone Purdue 11/20/2014 YES Morphabond morphine Inspirion 10/2/2015 NO Xtampza ER oxycodone Collegium 11/6/2015 YES Troxyca ER oxycodone + naltrexone Pfizer 8/22/2016 NO Arymo ER morphine Egalet 1/9/2017 Limited Vantrela ER hydrocodone Teva 1/18/2017 NO RoxyBond oxycodone Inspirion 4/26/2017 NO 26
27 27 Systematic Review of Abuse Deterrent (Tamper Resistant) Formulations Question: What is the evidence that opioid analgesics with abuse deterrent labeling improve outcomes (abuse, misuse, overdose, death)? 45 reports on opioids with abuse deterrent labeling o Hydrocodone (n=7) o Morphine (n=5) o Oxycodone (n=32)* Hill Criteria Also assessed confounding factors and bias Dart, Iwanicki, Dasgupta, Cicero, Schnoll. J Opioid Manag
28 RADARS : Change in Abuse after OxyContin Reformulation PC OTP SKIP DD Dart, Iwanicki, Cicero, Dasgupta, Scholl. J Opioid Manag
29 Nonmedical Use of OxyContin, National Survey of Drug Use and Health, Reformulation 29
30 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 30
31 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER Oxycodone ER Reformulation % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 31
32 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines Oxycodone ER Reformulation % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 32
33 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 33
34 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation FL % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 34
35 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation FL TIRF REMS % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 35
36 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation FL TIRF REMS ER/LA REMS % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 36
37 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation FL TIRF REMS ER/LA REMS HC-APAP Tramadol % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 37
38 Rate adjusted for population Percent of Population Covered by PDMP Timeline of Interventions vs. Oxycodone ER WA Rx Guidelines National Drug Take Back Oxycodone ER Reformulation FL TIRF REMS ER/LA REMS HC-APAP Tramadol CDC % % % Oxycodone ER PDMP 70% 60% 50% Other Opioids 40% 30% 0 20% All Other Opioids (per 100,000 population) Oxycodone ER (per 10,000 population) PDMP Coverage 38
39 Problems with a Reactionary Agenda 39
40 Problems with a Reactionary Agenda OxyContin is the Problem 40
41 Problems with a Reactionary Agenda OxyContin is the Problem Drug manufacturers are the Problem 41
42 Problems with a Reactionary Agenda OxyContin is the Problem Drug manufacturers are the Problem Addicts / Drug dealers are the Problem 42
43 Problems with a Reactionary Agenda OxyContin is the Problem Drug manufacturers are the Problem Addicts / Drug dealers are the Problem The core problem is human frailty and susceptibility to opioids (or perhaps to mind altering substances in general?) 43
44 Problems with a Reactionary Agenda OxyContin is the Problem Drug manufacturers are the Problem Addicts / Drug dealers are the Problem The core problem is human frailty and susceptibility to opioids (or perhaps to mind altering substances in general?) When we are looking back at the past 44
45 45
46 46
47 Heroin - Push? Or Pull? Alcohol Marijuana Polysubstance Abuse Heroin (Fentanyl) Opioid Abuser Availability Cost Setting Other Drugs IR Rx Opioid ER Rx Opioid
48 Heroin - Push? Or Pull? Alcohol Marijuana Polysubstance Abuse Heroin (Fentanyl) Opioid Abuser Availability Cost Setting Other Drugs IR Rx Opioid ER Rx Opioid
49 Heroin - Push? Or Pull? Alcohol Marijuana Polysubstance Abuse Heroin (Fentanyl) Opioid Abuser Availability Cost Setting Other Drugs IR Rx Opioid ER Rx Opioid
50 How Else Might Someone Cope? Opioids Opioids that you didn t think were opioids Non-opioids
51 Loperamide (Immodium) Antidiarrheal Prescription and OTC Intestinal mu agonist Poor systemic absorption due to p-glycoprotein Abused alone or in combination with opioids
52 Loperamide Abuse National Poison Data System Miller H et al. JAPHA 2017, 57(2): S45 S50
53 Slide on Loperamide Deaths
54 GABA Analogs Gabapentin, pregabalin 10-15% prescribed opioids also prescribed gabapentin Misuse common in opioid use disorders (15% - 28%) Increased mortality when combined with opioids o Likely synergistic respiratory depression
55 RADARS: Diversion of GABA Analogs Rates of gabapentin diversion (per 100,000) by quarter,
56 Gabapentin Pregabalin 56
57 Gabapentin and Mortality Gomes et al. PLoS Med Oct; 14(10): e
58 Antipsychotic Medications Atypical antipsychotics commonly abused both alone and in combination with other drugs Especially popular in incarcerated population Quetiapine (Seroquel) often drug of choice
59 Antipsychotic Abuse 429 patients from detox and rehab units 73 (17%) abuse atypical antipsychotics with alcohol, opioids, cocaine/crack, methamphetamine, and/or cannabis Quetiapine most common (84.9%) Other antipsychotics - olanzapine (17.8%), risperidone (24.7%), aripiprazole (20.5%), ziprasidone (8.1%), and asenapine (2.9%) Goals: "getting mellow, "slowing down, or enhancing effects of other drugs American Academy of Addiction Psychiatry (AAAP) 24th Annual Meeting & Symposium 59
60 Quetiapine DAWN ED visits Mattson et al. Subst Abuse May 24;9: doi: /SART.S ecollection 2015.
61 Antidepressants Reports of abuse of all classes May have higher rates with SNRI o Stimulant effects due to norepinephrine reuptake inhibition o When used with opioids, pharmaceutical speedball effect o Adverse effects include seizures and dysrhythmias
62 Cyclobenzaprine National Poison Data System (NPDS) Few studies of misuse/abuse Anticholinergic effects Structural similarity to tricyclic antidepressants Anticipate synergistic CNS and respiratory depression with opioids
63 Other Anticonvulsants Nearly all have been reported both in single substance and polysubstance abuse cases Levitiracetam may be on the horizon Synergistic CNS depression with opioids Cardiac effects also possible
64
65 65
66 Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States OBJECTIVE State medical cannabis laws related to opioid analgesic overdose mortality? DESIGN, SETTING, AND PARTICIPANTS Time-series analysis of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included. Bachhuber MA, et al. JAMA Intern Med. 2014; 174(10):
67 Deaths from Opioid Analgesic Bachhuber MA, et al. JAMA Intern Med. 2014; 174(10):
68 Deaths from Opioid Analgesic Bachhuber MA, et al. JAMA Intern Med. 2014; 174(10):
69 Deaths from Opioid Analgesic Bachhuber MA, et al. JAMA Intern Med. 2014; 174(10):
70 Deaths from Opioid Analgesic
71 National Epidemiologic Survey on Alcohol Methods and Related Conditions (NESARC) o Associations between cannabis use at wave 1 ( ) and nonmedical prescription opioid use and prescription opioid use disorder at wave 2 ( ) of NESARC. o Cannabis and prescription opioid use by structured interview. o Other covariates included age, sex, race/ethnicity, anxiety or mood disorders, family history of drug, alcohol, and behavioral problems, and nonmedical opioid use.
72 NESARC: Cannabis Use Associated with Increased Opioid Use Cannabis use at wave 1 associated with o Increased incident nonmedical prescription opioid use (odds ratio=5.78, 95% CI= ) o Increased opioid use disorder (odds ratio=7.76, 95% CI= ) at wave 2
73 NESARC: Cannabis Use Associated with Increased Opioid Use Cannabis use at wave 1 associated with o Increased incident nonmedical prescription opioid use (odds ratio=5.78, 95% CI= ) o Increased opioid use disorder (odds ratio=7.76, 95% CI= ) at wave 2 Associations remained significant after adjustment for background characteristics.
74 NESARC: Cannabis Use Associated with Increased Opioid Use Cannabis use at wave 1 associated with o Increased incident nonmedical prescription opioid use (odds ratio=5.78, 95% CI= ) o Increased opioid use disorder (odds ratio=7.76, 95% CI= ) at wave 2 Associations remained significant after adjustment for background characteristics. Among adults with pain at wave 1, cannabis use was also associated o Increased incident nonmedical opioid use (adjusted odds ratio=2.99, 95% CI= ) at wave 2
75 Conclusions Abuse and death of analgesic opioids are decreasing o Heroin and illicit fentanyl deaths are increasing more 75
76 Conclusions Abuse and death of analgesic opioids are decreasing o Heroin and illicit fentanyl deaths are increasing more Dramatic changes in heroin distribution has rapidly changing the opioid abuse environment o Just call Givememyfix 76
77 Conclusions Abuse and death of analgesic opioids are decreasing o Heroin and illicit fentanyl deaths are increasing more Dramatic changes in heroin distribution has rapidly changing the opioid abuse environment o Just call Givememyfix Squeezing the Balloon may also affect non-opioids 77
78 Conclusions Abuse and death of analgesic opioids are decreasing o Heroin and illicit fentanyl deaths are increasing more Dramatic changes in heroin distribution has rapidly changing the opioid abuse environment o Just call Givememyfix Squeezing the Balloon may also affect non-opioids Cannabis may or may not affect opioid use o Studies intriguing, but stronger analytic designs needed 78
79 Questions?
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