The opioid crisis: A view from NIDA

Transcription

1 The opioid crisis: A view from NIDA National Institute on Drug Abuse Bringing the full power of of science to bear to bear on drug on drug abuse abuse and addiction and addiction Nora D. Volkow, M.D. Director National Institute on Drug Abuse Carlos Blanco, M.D., Ph.D. Director, Division of Epidemiology, Services and Prevention National Institute on Drug Abuse Science = Solutions

2 Develop a Learning Health Care System Using Clinical Practice to Generate Meaningful Research Questions Ensuring that Research Findings are Applied to Practice

3 Addiction is a Disease of the Brain EXECUTIVE FUNCTION/ INHIBITORY CONTROL OFC MOTIVATION/ DRIVE PFC ACG SCC NAcc Amyg VP Hipp MEMORY/ LEARNING REWARD

4 1. Reward Circuit NAcc VP REWARD Drugs of Abuse Engage Systems in the Reward Pathways of the Brain

5 2. Memory circuit Hipp Amyg MEMORY/ LEARNING People, Place and Things

6 3. Motivation & Executive Control Circuits Dopamine is also associated with motivation and executive function via regulation of frontal activity. EXECUTIVE FUNCTION PFC INHIBITORY CONTROL ACG OFC SCC MOTIVATION/ DRIVE

7 The fine balance in connections that normally exists between brain areas active in reward, learning and memory, motivation and inhibitory control EXECUTIVE FUNCTION INHIBITORY CONTROL PFC MOTIVATION/ DRIVE ACG OFC SCC NAcc Amyg Hipp VP REWARD MEMORY/ LEARNING Becomes severely disrupted in ADDICTION

8 ADDICTIONS as diseases of Gene-Environment-Development Addictions are common, developmental brain diseases expressed as compulsive behavior through continued use of a drug despite negative consequences: Onset depends on many intrinsic and extrinsic factors. Biology Genes/Development Environment DRUG/ALCOHOL Brain Mechanisms Addiction

9 RISK FACTORS FOR SUBSTANCE USE DISORDER Family History Childhood Disturbed FamilyChildhood of SUD Sexual Abuse Environment Parental Loss Impulsivity Low Early-Onset Early-Onset Self-Esteem Anxiety SU Social Deviance Low Education Ever Divorced Low Social Marital Support Problems in DRUG AVAILABILITY History of Trauma Low Religious Services History of SUD Stressful Life Events SUD LAST YEAR Psychiatric Comorbidity Social Deviance Social Deviance

10 Natural course of recovery for four substances Lopez-Quintero et al.,

11 Percent Switching Addictions? New Onset SUD With SUD Remission Did Not Remit P<.001 Data are from NESARC Waves 1 and 2 Blanco et al., JAMA Psychiatry

12 Develop a Learning Health Care System Using Clinical Practice to Generate Meaningful Research Questions Ensuring that Research Findings are Applied to Practice

13 Key Drug Abuse Public Health Crisis The NEW ENGLAND JOURNAL of MEDICINE REVIEW ARTICLE Relationship between Nonmedical Prescription-Opioid Use and Heroin use Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D, M.P.H. and Grant T. Baldwin, Ph.D., M.P.H. January 14, 2016 Opioid Drug Abuse: Prescription Opioids AND Heroin JAMA The Journal of the American Medical Association October 13, 2015 Original Investigation Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, Beth Han, MD, PhD; Wilson M. Compton, MD, MPE; Christopher M. Jones, PharmD, MPH; Rong Cai, MS

14 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Overdose Deaths Continue to Increase 16,849 63,632 52,404 47,055 Source: Data Brief 294. NCHS, National Vital Statistics System, Mortality

15 Changing Outcomes:Fentanyl Overtakes Heroin as Leading Cause of U.S. Drug Death JOSH KATZ SEPT. 2, 2017 Drug overdoses killed roughly 64,000 people in USA in 2016; 22% rise over Fentanyls are changing equation: Death rate in Maryland last year outpaced that in Kentucky and Maine. Estimate U.S. Drug Deaths in 2016 Graph from NY Times Article based on CDC MMWR Report 2017

16 Rising rates of HCV Counties Deemed Highly Vulnerable to Rapid Dissemination of HCV or HIV 3,000 2,500 2,000 1,500 1, Number of cases3,500 ~31,000 new HCV infections in :1 male: female ratio, predominantly white National Notifiable Diseases Surveillance System (NNDSS) HIV (and Hepatitis C) Outbreak Linked to Oxymorphone Injection Use in Indiana, 2015 Peters et al. The New England Journal of Medicine 2016;375: Source: Van Handel et al, JAIDS 2016

17 Science = Solutions : Opioid Use and Misuse During Pregnancy Increasing NICU Admissions for Neonatal Abstinence Syndrome NAS (per 1000 Admissions) Increasing Costs for Neonatal Exposure Source: Tolia VN, Patrick SW, et al., NEJM 2015;372: Source: Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SM.. Pediatrics. 2018;141(4):e

18 Percent Overlap of Benzodiazepines and Opioids Opioid Analgesic ED Visits and OD Deaths Involving Benzodiazepines & Benzodiazepine ED Visits and OD Deaths Involving Opioids AAPC = 1.5% (95% CI 0.8%-2.2%) AAPC = 8.4% (95% CI 7.1%-9.7%) AAPC = 3.0% (95% CI 1.3%-4.8%) AAPC = 4.5% (95% CI2.4%-6.6%) 0 Deaths Involving Benzodiazepines ED Visits Involving Benzodiazepines Deaths Involving Opioid Analgesics ED Visits Opioid Analgesics Opioid Analgesics Benzodiazepines Source: CM Jones, JK McAninch. American Journal of Preventive Medicine 2015;49:

19 Heroin Market Has Changed: Heroin Price Has Been Lower in Recent Years $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $- "Retail" Price Per Pure Gram Source: National Drug Control Strategy--Data Supplement

20 High Levels of Opioid Prescriptions have Facilitated Diversion & Contributed to Overdose Deaths Near Tripling of Opioid Prescriptions from U.S. Retail Pharmacies, Total Rx Opioid Tablets Dispensed in Retail Pharmacies in the USA: ,972,304, ,606,882,755 Source: Jones CM, et al. JAMA Internal Medicine 2016: doi: /jamainternmed IMS Health, Vector One : National, IMS Health, National Prescription Audit,

21 Prescriptions (millions) OPIOID MME IN BILLIONS Opioid Prescriptions Opioid morphine milligram equivalents (MME) dispensed fell by over 15% from Opioids Hydrocodone Oxycodone IMS Health, U.S. Outpatient Retail Setting

22 NIH OPIOID RESEARCH INITIATIVE Using Research to End the Opioid Crisis PREVENTION OUD PAIN MANAGEMENT Safe, more effective strategies OPIOID ADDICTION TREATMENT New and innovative medications and technologies OVERDOSE REVERSAL Interventions to reduce mortality and link to treatment

23 1. Inadequate Pain Treatment as a Driver 91.8 million adults used prescription opioids (37.8% of the U.S. adult population) 11.5 million adults misused prescription opioids (4.7% of the U.S. adult population) 1.9 million adults had prescription opioid use disorders (0.8% of the U.S. adult population) relieve physical pain relax or relieve tension experiment get high or feel good help with sleep 11.2 help with emotions or feelings 66.3 increase/decrease effects of other drugs hooked or have to misuse other reason Source: Han, Compton, et al. Annals of Internal Medicine 2017 (epub Aug 1, 2017)

24 2. Direct Overdose Intervention Naloxone Distribution for opioid overdose victims. The potential for direct intervention to save lives. Note the April 3, 2014 FDA approval of the naloxone auto-injector (called Evzio ) Naloxone Nasal Spray Development Needle-free, unit-dose, ready-to-use opioid overdose antidote. Adapt Pharma NARCAN nasal spray APPROVED BY FDA, November 18, Science = Solutions

25 3. Medication Diversion: Prevention/brief interventions People misusing analgesics Directly & Indirectly obtain them by prescription Source where pain relievers obtained for most recent misuse Prescription 36% Other 1 Friend/ Relative 5 87% Their Prescription Other 3% 1 Their Friend/Relative Source: SAMHSA, 2015 National Survey on Drug Use and Health.

26 Doctors (and other clinicians) Need to Know What Prescriptions Have Been Given to Their Patients By Other Practitioners This information should be: 1. included in the patients electronic health care records 2. accessible through a Prescription Drug Monitoring Program (PDMP) that provides immediate information

27 Opioid Effect 4. OUD Cascade of Care Medication Assisted Treatment (MAT) OUD Cascade of Care in USA Log Dose Full Agonist (Methadone: Daily Dosing) Partial Agonist (Buprenorphine: 3-4X week) Antagonist (Naltrexone: ER 1 month) DECREASES: Opioid use Opioid-related overdose deaths Criminal activity Infectious disease transmission INCREASES Social functioning Retention in treatment But MAT is highly underutilized! Relapse rates are very high! Current estimates Treatment gap 90% goal Williams AR, Nunes E, Olfson M. Health Affairs Blog, 2017.

28 Accessing Medications Can Save Lives Opioid Agonist Treatments Decreased Heroin OD Deaths Baltimore, Maryland, Heroin overdoses Buprenorphine patients Methadone patients Schwartz RP et al., Am J Public Health Science = Solutions

29 In 48 states and D.C., Opioid Use Disorder Rates Exceed Buprenorphine Treatment Capacity Jones C et al., Am J Public Health Medications are Underused 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% In 2014, only 25% of opioid admissions had treatment plans that included receiving medications. 100% % Treatment Programs Offering FDA-approved SUD Medications 25% 9% 17% 9% 16% 19% 25% MAT 75% No MAT Treatment Episode Data Set (TEDS): Knudsen et al., J Addict Med 2011

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31 Develop a Learning Health Care System Using Clinical Practice to Generate Meaningful Research Questions Ensuring that Research Findings are Applied to Practice

32 Why is an LHS important? Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe

33 What is an LHS? According to the National Academy of Medicine, one that uses: Science and Informatics Patient-Clinician Partnerships Incentives and Culture To enable continuous real-time improvement in: Effectiveness Efficiency of care Source: National Academy of Medicine, Best Care at Lower Cost, 2013

34 In reality A Feedback Loop from Research to Practice Role of Practice: Question generation Role of Research: Find generalizable answers Practice and Research defined broadly

35 Traditional View of Innovation Rogers E, Diffusion of Innovations, 1962

36 LHS View of Innovation Green et al., Ann Int Med, 2002;157:

37 Summary Addictions can be prevented and treated. Complex biological, developmental and social aspects of substance abuse and addiction suggest multipronged responses. Science provides clues and is essential in planning responses. There is a need to develop a learning healthcare system

38 Develop a Learning Health Care System Using Clinical Practice to Generate Meaningful Research Questions Ensuring that Research Findings are Applied to Practice