Washington State s Overdose Epidemic

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1 Caleb Banta-Green PhD MPH MSW Senior Research Scientist- Alcohol and Drug Abuse Institute Affiliate Associate Professor- School of Public Health Affiliate Faculty- Harborview Injury Prevention & Research Center University of Washington May 5, 2015 Washington State s Overdose Epidemic

2 Outline Opiate deaths- 3 major types Prescribing of opioids Police evidence data Treatment data Mortality data Rx to Heroin why and what to do about it

3 Opioid involved deaths Type of Opioid & Source Heroin Rx-type Opioids Not- prescribed Rx-type Opioids Prescribed Proportions approximate

4 Opioid involved deaths Underlying medical issues SUBSTANCE ABUSE PAIN Proportions approximate

5 Opioid involved deaths Heroin PAIN Rx-type Opioids Notprescribed Rx-type Opioids Prescribed Proportions and overlap approximate Mental Health issues very common across all groups

6 Implications of death data Different types of opioids- Heroin & Rx Different motivations for use Pain (physical/psychological) Substance Abuse Both Different sources- street, friend, prescription

7 Opioid Prescribing- History 1996 WA Medical commission recommends more opioid prescribing for chronic pain 2003 WA takes OxyContin off Medicaid formulary 2007 State pain/opiate guidelines 2010 OxyContin changed- can t be crushed 2012 State pain/opiate law 2012 Prescription Monitoring Program available

8 Prescribing for most opioids began leveling off around SOURCE: DEA ARCOS- Sales to Hospitals and Pharmacies

9 Opioid prescribing in WA 2013 Source: Prescription Monitoring Program- Preliminary Data By use pattern Acute Long term <90 days supply >120 days supply or 10+ Rx Unique people in ,289, ,609 Age 45.4 (20.4) 55.8 (15.4) Cumulative days supply 11.7 (15.8) 334 (221.2) No. of prescriptions 1.9 (1.7) 14.6 (10.5) % with sedatives 46.2 Data- WA Dept of Health Analyses- Alcohol & Drug Abuse Institute & School of Pharmacy U.W.

10 State crime lab data Police evidence sent by local law enforcement jurisdictions for testing Rough measure of what s available on the street

11 Data source: WA State Patrol- Forensic Lab Services Bureau

12 In Eastern Washington: local police evidence testing increased 79% totaled 3,502 cases Data source: WA State Patrol- Forensic Lab Services Bureau

13 Treatment admissions Influenced by demand and availability for treatment Publicly funded treatment data- inpatient, outpatient, and medication assisted treatment Small proportion of buprenorphine admits- included Buprenorphine treatment estimate from Prescription Monitoring Program Based upon prescribing in general medical practice, not in treatment program

14 Data source: DSHS/DBHR TARGET

15 In Eastern Washington increased 103% and totaled 3,084 Data source: DSHS/DBHR TARGET

16 Data source: DSHS/DBHR TARGET

17 Buprenorphine prescribed by physicians approved to use for addiction treatment in 2013 Rate per 100,000 population Source: WA Dept. of Health Prescription Monitoring Program. Analyses conducted by the University of Washington. Based upon patients zip code of residence, with zip code apportioned to county by Looking Glass Analytics algorithm. Buprenorphine prescription for a prescriber authorized to use for addiction treatment Does not include buprenorphine used in a drug treatment facility.

18 Drug caused deaths involving opioids

19 Age-adjusted Rate per 100,000 Data source: WA State Dept of Health Drug Overdoses, WA, Total Opioid Overdose Prescription Opioid Overdose Heroin Overdose (estimated) Year of Death King County data indicate recent heroin increases mostly <30 years of age

20 In Eastern Washington Approximately 2 opiate involved deaths per week over this time frame Data source: WA State Dept of Health

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22 Pain Pills to Heroin?

23 WA Healthy Youth Survey 10 th graders in 2012

24 2013 Syringe Exchange Survey King County Heroin Users by Age Source: Public Health- Seattle & King County, Emily Cederbaum analyses *Statistically significant

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26 Access issues Most teens get Rx opiates from Own Rx (33%) A friend (28%) Family gave (10%) Took from a home (9%) Don t accept unneeded Rx s Dispose of unneeded medicines Lock up medications that are needed

27 Preventing Inappropriate initiation of Rx opioids In 2013 in WA state more than 1 in 4 people had at least one prescription for a controlled substance (e.g. Vicodin, Valium, Ambien) More than half of adults take a prescription medicine of any kind.

28 Taking prescription medicines is now typical and normal Talking about medication usage with family members purposefully and thoughtfully and the role of medications in health is not yet normal.

29 Motivation & Liking Motivation issues Social-peers Sensation seeking- high/euphoria/fun Physical pain- Emotional pain- stress/trauma/escape Family norms- Health beliefs/stress/medication beliefs Set & Setting A teen sharing their Oxy at a kegger is different than short term opiates for severe acute injury Liking- aversive and reinforcing properties of the drug Biological- energized vs sleepy; genetics/metabolization Psychological- feel normal vs agitated

30 Parents should reflect on their own use of alcohol/medication/drugs Consider what messages they are sending e.g. emotional language- taking to relax Determine if they are the messages they want to be sending Consider their youths situation- e.g. trauma Be explicit about reasons for their use and expectations for youth This may be hard and involve the adult seeking help

31 Tolerance and Withdrawal Repeated use of opiates leads to tolerance Which leads to needing more to get the same effect Stopping use leads to withdrawal, which feels terrible (not fatal) So you continue to use

32 Changing route of ingestion Seeking euphoria- snorting, smoking and injecting are more intense highs Shorter more intense highs can also lead to quicker cycles of highs and lows and reinforce use Social situations, new friends may be using opiates in different ways and contexts Initiating injecting doesn t happen in a vacuum

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34 OXYCODONE

35 HEROIN MORPHINE

36 OXYCODONE MORPHINE

37 OXYCODONE MORPHINE (heroin metabolite) $80 $10 & easier to get

38 Preventing Infectious Disease Anyone who has injected drugs whether currently using or not needs to learn about infectious disease prevention and testing HIV and HCV Need to use a new needle each time

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40 Conclusion Rx Opioid and Heroin use, addiction, and deaths have spread across the state Young adult use increasing quickly As you will learn, we are fortunate to have excellent medicines for opioid addiction and reversing opioid overdoses