The Prescription Opioid and Heroin Crisis: Responding to An Epidemic of Addiction

Transcription

1 The Prescription Opioid and Heroin Crisis: Responding to An Epidemic of Addiction Andrew Kolodny, M.D. Chief Medical Officer, Phoenix House Foundation Inc. Executive Director, Physicians for Responsible Opioid Prescribing Senior Scientist, Heller School for Social Policy and Management, Brandeis University Research Professor, Global Institute of Public Health, New York University

2 The Opium Poppy Papaver Somniferum 2

3 Opium 3

4 Opioids Morphine Codeine Thebaine Heroin Naturally occurring opioidsalso called opiates Hydrocodone (Vicodin) Oxycodone (Oxycontin) Oxymorphone (Opana) Hydromorphone (Dilaudid) Semi-synthetic opioids

5 Death rate per 100,000 Unintentional Drug Overdose Deaths United States, ,982 drug overdose deaths in Heroin Cocaine 0 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 Year National Vital Statistics System,

6 Number of Deaths Drug Overdose Deaths by Major Drug Type, United States, ,000 Opioids Heroin Cocaine Benzodiazepines 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, Year CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

7 Opioid Related Overdose Deaths United States, ,000 24,000 22,000 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Painkillers Heroin Total Opioid Year

8 Heroin admissions, by age group & race/ethnicity:

9 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 9

10 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 10

11 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 11

12 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 12

13 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 13

14 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 14

15 Non-heroin opioid admissions, by gender, age, race/ethnicity:

16 Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., Number of Deaths '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 * Opioid sales (mg/person) Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary.

17 Rate 8 Rates of Opioid Sales, OD Deaths, and Treatment, Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10, Year CDC. MMWR 2011

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20 Dollars Spent Marketing OxyContin ( ) Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion and Efforts to Address the Problem.

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22 Industry-funded education emphasizes: Opioid addiction is rare in pain patients. Physicians are needlessly allowing patients to suffer because of opiophobia. Opioids are safe and effective for chronic pain. Opioid therapy can be easily discontinued. 22

23 Industry-funded organizations campaigned for greater use of opioids Pain Patient Groups Professional Societies The Joint Commission The Federation of State Medical Boards 23

24 The risk of addiction is much less than 1% Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med Jan 10;302(2):123 Cited 824 times (Google Scholar) 24

25 N Engl J Med Jan 10;302(2):

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27 Urine Tox Results in Chronic Pain Patients on Opioid Therapy Source: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug use in the chronic pain population. Popul Health Manag. 2009;12(4):

28 Controlling the epidemic: A Three-pronged Approach Prevent new cases of opioid addiction. Treatment for people who are already addicted Supply control- Reduce over-prescribing and black-market availability. 28

29 Perceived Risk by 8 th Graders Occasional heroin use without a needle is high risk: 73% Occasional Vicodin use is high risk: 26% Occasional Vicodin use perceived as less risky than: Occasional marijuana use Moderate alcohol use Smoking 1 5 cigarettes per day Source: Johnston LD, O Malley PM, Bachman JG, Schulenberg JE Monitoring the Future. National Survey Results on Drug Use: Overview, key findings on adolescent drug use. Ann Arbor, MI: Inst. Soc. Res., Univ. Mich. 29

30 How the opioid lobby frames the problem: Source: Slide presented by Lynn R. Webster MD at FDA meeting on hydrocodone upscheduling, January 25 th, 2013.

31 4000 Non-medical use down since 2002, yet opioid OD deaths still rising Non-Medical Use Opioid OD Deaths Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu Rev Public Health. 2015: 36:

32 This is a false dichotomy Aberrant drug use behaviors are common in pain patients 63% admitted to using opioids for purposes other than pain 1 Pain Patients 35% met DSM V criteria for addiction 2 Drug Abusers 92% of opioid OD decedents were prescribed opioids for chronic pain. 1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8: Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30: Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, J Gen Intern Med Oct 16.

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34 Summary The United States is in the midst of the worst drug addiction epidemic in its history. Ending the epidemic requires: PREVENTING new cases of opioid addiction TREATMENT for people who are already addicted 34

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