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
The Opium Poppy Papaver Somniferum 2
Opium 3
Opioids Morphine Codeine Thebaine Heroin Naturally occurring opioidsalso called opiates 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.
Opioid Related 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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Dollars Spent Marketing OxyContin (1996-2001) Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion and Efforts to Address the Problem.
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
Industry-funded organizations campaigned for greater use of opioids Pain Patient Groups Professional Societies The Joint Commission The Federation of State Medical Boards 23
The risk of addiction is much less than 1% Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;302(2):123 Cited 824 times (Google Scholar) 24
N Engl J Med. 1980 Jan 10;302(2):123. 25
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):185 190. 27
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
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. 2014. Monitoring the Future. National Survey Results on Drug Use: 1975 2013. Overview, key findings on adolescent drug use. Ann Arbor, MI: Inst. Soc. Res., Univ. Mich. 29
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.
4000 Non-medical use down since 2002, yet opioid OD deaths still rising 25000 3500 3000 Non-Medical Use Opioid OD Deaths 20000 2500 15000 2000 1500 10000 1000 500 5000 0 0 Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu Rev Public Health. 2015: 36:559-574
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;8:573-582. 2. 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;30:185-194. 3. 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, 2008-2009. J Gen Intern Med. 2012 Oct 16.
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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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