Responding to the Opioid Addiction Epidemic 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
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Opioids Morphine Codeine Thebaine Naturally occurring opioidsalso called opiates Diacetylmorphine (Heroin) Hydrocodone (Vicodin) Oxycodone (Oxycontin) Oxymorphone (Opana) Hydromorphone (Dilaudid) Semi-synthetic opioids
Death rate per 100,000 Unintentional Drug Overdose Deaths United States, 1970 2007 10 9 43,982 drug overdose deaths in 2013 8 7 6 5 4 3 2 1 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, http://wonder.cdc.gov
Number of Deaths Drug Overdose Deaths by Major Drug Type, United States, 1999 2010 18,000 Opioids Heroin Cocaine Benzodiazepines 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
Number of Deaths Drug Overdose Deaths by Major Drug Type, United States, 1999 2010 18,000 Opioids Heroin Cocaine Benzodiazepines 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
Opioid Overdose Deaths United States, 1999-2013 26,000 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 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year
Heroin admissions, by age group & race/ethnicity: 2001-2011 8
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 9
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 10
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 11
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 12
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 13
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 14
Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011 15
Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., 1997-2007 14000 12000 10000 8000 6000 4000 2000 0 Number of Deaths '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 * Opioid sales (mg/person) 800 700 600 500 400 300 200 100 0 Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary.
Rate 8 Rates of Opioid Sales, OD Deaths, and Treatment, 1999 2010 7 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 6 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year CDC. MMWR 2011
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Industry-funded education on opioid use for chronic non-cancer pain: Doctors are needlessly allowing patients to suffer because of opiophobia Risk of addiction is very low Physical dependence is clinically unimportant Safe and effective for chronic pain 20
Controlling the epidemic: A Three-pronged Approach Prevent new cases of opioid addiction. Treat people with disease of opioid addiction. Control supply from pill mills and blackmarket availability. 21
Buprenorphine Experience in France Introduced in the mid 90s 80% decline in OD deaths in 6 years Associated with diversion and injection use Source: Emmanuelli J, Desenclos JC. Harm reduction interventions, behaviours and associated health outcomes in France, 1996 2003. Addiction 2005;100:1690 1700.
How Full Agonists Work
Buprenorphine is a Partial Agonist
Oxycodone for Chronic Pain Vs. Buprenorphine for Addiction Oxycodone for Chronic Pain Buprenorphine for Addiction Evidence-Based Treatment No Yes Controlled Drug Schedule CII CIII Overdose Risk High Low Training Requirement None 8 Hour Course Number of patients Unlimited 30/100 NPs/PAs allowed to Rx Yes No
Barriers to Buprenorphine Ideological Federally imposed patient caps Federally imposed ban on NP and PA prescribing Limited integration of addiction treatment in primary care
Remaining in treatment (nr) Retention in Treatment Kakko, Lancet 2003 20 15 10 5 0 Detoxification Maintenance 0 50 100 150 200 250 300 350 Treatment duration (days)
Buprenorphine RCT A Tragic Appendix: Mortality Kakko, Lancet 2003 Placebo BPN Dead 4/20 (20%) 0/20 (0%)
Summary The U.S. is in the midst of a severe epidemic of opioid addiction To bring the epidemic to an end: We must prevent new cases of opioid addiction We must ensure access to treatment for people already addicted