JAY WEISS, MD JULY 13, 2018

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1 Opioid Epidemic Mississippi Opioid and Heroin Summit JAY WEISS, MD JULY 13, 2018

2 Overview Scope of problem History Biopsychosocial Anatomy Neurotransmitters Pain and depression Treatment and relief

3 Scope of Problem 1 USA-More RX opioids than other countries 99% of HCD RX in world 13.5% lifetime prevalence for SUD 50% ER admits substance-related(1/7) 1/32 receiving chronic opioids will OD/die 2.5 million in US addicted to opioids (1.9 million RX, 0.5 million to Heroin 55 billion /year societal costs

4 Scope of Problem 2 Opioid OD up 4x Pain as 5 th vital sign JCAHO emphasis Press-Ganey scores Patient Satisfaction DR. Murthy letter August 2016 Legal Actions Against Prescribers High RX rates and patient mortality

5 History BC Sumerians Joy Plant (Opium) 330 BC Alexander brought opium to India 250 AD Hua Tuo Chinese Surgeon gave opium to patients before surgery 1680 Thomas Syndenham- Laudanum 1804 Morphine isolated from opium 1856 Hypodermic syringe brought to USA 1860s US Civil War and morphine 1874 Heroin non addictive alternative

6 History Bayer Heroin and Aspirin 1914 Harrison act. Gatekeepers 1916 Oxycodone less addictive 1918 Prohibition 1920 Docs in jail 1924 Heroin act 1970 Controlled substances act 1972 Methadone clinics (stigma)

7 History DEA and war on drugs. Nixon 1980s. Opioids and chronic pain 1990s Aggressive lobbying for opioids million RX for opioids (a bottle for every adult in USA) 2015 HCD to Schedule II. Heroin skyrockets El Chapo Business Model- Cannabis to Heroin US Surgeon General letter MAT Buprenorphine (Subutex and Suboxone)

8 History 4 Opioids used in 1700s to treat pain, cough, diarrhea, communicable diseases Bayer ceased production of Heroin in addicts / s addicts/ Physicians able to slow and reverse addiction to Morphine Doctors better educated and informed by 1910 Harrison Narcotics Act 1914

9 Biopsychosocial Biological Biological predilection. Runs in families. Lock in key theory. Exaggerated response Warm blanket, felt normal, forgot about abuse, at peace, relaxed, energized Hedonic tone theory. Euphoria to dysphoria Genetic factors

10 Biopsychosocial Psychological Psychiatric comorbidity Odds ratios: Association with Opioid RX Major depression 3.43 Dysthymia 6.51 Panic Disorder 5.37 Generalized Anxiety Disorder 2.56 Chicken or egg argument

11 Biopsychosocial Social History of abuse Current trauma Stress at work or home Poor nutrition Multiple drug use Multiple Doctors Multiple Pharmacies

12 Anatomy

13 Anatomy

14 Limbic System

15 Anatomy Nucleus Accumbens Ventral Tegmental Area Corpus Callosum Amygdaloid Nucleii Mammillary Bodies Prefrontal Cortex Primitive-Survival-Reptile Brain

16 Anatomy Limbic system fully developed in adolescence Frontal lobes not fully developed until age 22 Limbic system is reptile brain, animal drives, pleasure and reward, emotions, Freud s Id, Frontal lobes are limitations, right and wrong, Freud s Superego Addiction hijacks pleasure/reward pathways Crank up Id, Shut down Superego Smart folk do stupid stuff

17 Stop and Go Limbic system is go for food, sex, thirst, safety, fight or flight, survival. Five F activity. Survival Frontal and prefrontal cortex are stop, fear of consequences, limits Drugs crank up go and inhibit stop Dopamine sits at the junction of reward and addiction

18 Neurotransmitters Alcohol-GABA Amphetamines and Cocaine-Dopamine Benzodiazepines and GHB-GABA Cannabis-Anandamide Hallucinogens and MDMA- Serotonin Nicotine-Acetylcholine Opioids- Endorphins PCP and Ketamine- Glutamate

19 Dopamine 1 Dopamine sits at junction of reward, mood, pleasure, psychosis, and addiction Nigrostriatal pathway: movement, Parkinson s Mesolimbic pathway: reward and pleasure Tuberoinfundibular pathways: Pituitary hormones, mostly prolactin Multiple issues: cognition, thought, emotion, pain

20 Dopamine 2 Multiple issues: Pain, insomnia, mood Reward, reinforcement, learning, memory Food, food cravings, music, risk taking and well being, exercise, locomotion Connector. Interacts with other neurotransmitters Balance: Acetylcholine/Dopamine Dopaminergics and Anticholinergics

21 Dopamine 3 Too much dopamine: Psychosis. Crazy behavior. Hallucinations. Delusions. Give antipsychotics. (All antipsychotics block dopamine) Too little dopamine: Parkinson's. Give Levodopa All drugs of abuse boost dopamine levels Amphetamine worst Cocaine next worst Five F activity boosts dopamine

22 Dopamine/Acetylcholine Balance Dopamine Acetylcholine /\ Psychosis Antipsychotics Parkinson s, Dystonias Organophosphates Nerve Agents Anticholinergics Dopaminergics

23 Pain 1 Pain, depression, and fear of pain 80% of pain emotional Spinothalamic tract: Awareness/sensation Spino-reticular tract: Suffering Spino-mesencephalic tract: mood, serotonin, natural opioid secretion of endorphins and enkephalins

24 Pain 2 Opioids for pain management Relief within first month, or opioids unlikely to be effective. Long-term opioid treatment of chronic non-malignant pain rarely effective Opioid induced hyperalgesia. Tolerance. No longer work. One week. Withdrawal symptoms

25 Non-Opioid Treatment Nonsteroidal anti-inflammatories Turmeric Tylenol Antidepressants Physical therapy, massage, chiropractic Moderate exercise Relaxation/meditation

26 Hyperalgesia Exogenous opioids shut down production of endogenous opioids Endorphins and Enkephalins Endogenous work better (no tolerance) Exogenous stop working at 1-2 weeks (tolerance) Pain increases with chronic exogenous opioids Pain decreases with cessation of external opioids and regeneration of internal opioids at about one month

27 Opioid Treatment 1 CDC Guidelines Use sparingly Assess pain and function Consider non-opioid alternatives Evaluate risk of harm or misuse Start low, go slow Short or intermediate acting, not ER

28 Opioid Treatment 2 Acute pain problem No more than three day supply No refills Check drug monitoring program Urine drug screen Avoid concurrent opioid and benzo RX

29 Opioid Treatment 3 Morphine milligram equivalents (MME) 50 MME = 50 mg HCD, 33 mg OXYCD 90 MME = 90 mg HCD, 60 mg OXYCD Less than 50 MME per day is much safer than MME per day Do not exceed 90 MME per day Higher risk of sedation and overdose as RX dose climbs

30 Pain and Depression 1 Pain, anxiety, fear, depression Similar pathways Norepinephrine, dopamine, and serotonin Antidepressants: Treat depression, anxiety, insomnia, pain, mood stabilization 1-2 weeks for noticeable difference 1-2 months for maximum effect

31 Pain and Depression 2 Opioids are CNS Depressants Sedatives are CNS Depressants ETOH is a CNS Depressant All exacerbate Depression Depression improves without these drugs Energy, interest, sleep, concentration, activity all improve without the drag of CNS Depressants

32 Conclusion Opioid problem severe, persistent Heroin skyrocketing We are repeating history. We overprescribed Sea change in Opioid prescribing Opioids good for acute pain (post-op) Not so good for chronic pain Tolerance and hyperalgesia Increased legal system involvement

Jay Weiss, MD Drug Summit Little Rock, Arkansas Sep 9/10, 2014

Jay Weiss, MD Drug Summit Little Rock, Arkansas Sep 9/10, 2014 OVERVIEW Definitions Disease concept Anatomy and neurochemistry Risk Factors Defenses, statistics, comorbidity Professionals and treatment