Opioid Epidemic:A Hopeful Roadmap for the

FutureDr. Ritu Bhatnagar, M.D., M.P.H.

Addiction PsychiatristApril 13, 2019

Disclosure statementNo conflicts of interest with this presentation.Financial Interests: portion of investment portfolio may have

stock in publicly traded pharmaceutical companies.

An Epidemic of New Proportions

From https://www.nytimes.com/interactive/2018/11/29/upshot/fentanyl-drug-overdose-deaths.html

Response?

How to make sense of the information?

“These trends are a wake-up call to a national well-being crisis.”

-- Trust For America’s Health National Resilience Strategy. https://www.tfah.org/report-details/pain-in-the-nation/

“It is better to light a candle than to curse the darkness.” -- Eleanor Roosevelt

The Science of Addiction

What is addiction?

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.”

Characterized by:Needing more of a substance to get same effectWithdrawal symptoms when substance is not availableCravings and urges for substance that interfere with social function

Involves the biology, psychology, social and spiritual aspects of a person.http://www.asam.org/quality-practice/definition-of-addiction

So, is Addiction a Disease?

From “Pleasure Unwoven”, Documentary with Dr. Kevin McCauley

From https://www.youtube.com/watch?v=h9ZzmoiRxSQ “Neurobiology of Addiction”

Comparing

DiabetesGenetic influencesExposure to sugarChange in pancreasBehaviors impact disease stateTreatment exists Accessible treatmentMinimal judgment

AddictionGenetic influencesExposure to substanceChange in brainBehaviors impact disease stateTreatment exists Less accessible treatmentLots of stigma

My clinical work

Practice of Medicine

Socio-economic Forces

Opioids

.1 Relevant history

The future

The year 2000

The ‘80s and ‘90s

2010 to present day

2

3

4

5

6

The early 2000s

1

Relevant History.1 Relevant

history

1620 Opium smoking

1806 Morphine isolated

1853 Syringe developed

1874 Heroin first synthesized in London

1898 Bayer marketed heroin as a “non-addictive morphine substitute and cough suppressant”

1910 Young working-class Americans learned to inhale heroin for a concentrated high

1924 US Congress banned sale, importation, or manufacture of heroin

1935 Narcotic Farm in Lexington, KY

Forces influencing the First Opioid EpidemicIndustrial revolution consequences: loss of jobs, economic insecurity

Physicians and pharmacists helped bring prescribing under control

U.S. came through it by creating a social safety net that provided a reset

The New Deal provided jobs, education, training, opportunities and hope for the public

Narcotic Addiction Treatment Act (1974)Narcotic: a drug or other substance affecting mood or behavior and sold for nonmedical purposes, especially an illegal one. Today, refers mostly to opioids.

NATA regulated the treatment of opioid addiction with methadone.

It created the daily dosing clinics.

Dosing, treatment and prescription tightly regulated.

Created its own stigma.

1980s and 1990s

War on Drugs

Social and economic changesCommercialization- Sackler drug advertising campaigns

Direct to consumer marketing:

Ability of corporations to push products without health and safety oversight

Led to increased influence of corporations on social norms

Changed cultural norms and social values

1900-1920s advertising

https://www.smithsonianmag.com/science-nature/how-advertising-shaped-first-opioid-epidemic-180968444/

1990s+ ad campaigns

Why the focus on pain?Editorial in NEJM in 1980 made the claim that only 4 of 12,000 patients treated with opioids in a hospital became addicted.

“We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.” -- Portenoy and Foley, Pain, 1986: 25: 2: 171-186.

In the early 1990s, American Pain Society declared a national epidemic of untreated pain in hospitals.

A slippery slope“Opioids [such as Oxycontin] are not addictive” message marketed heavily to physicians.

The Joint Commission, federal agency that regulates the practice of medicine, mandates that pain be measured and treated.

Pain became the 5th Vital sign.

The Fifth Vital Sign

“The misguided acceptance of pain as the fifth vital sign has been, and still is, the single biggest mistake in the history of modern medical pain management.” -- Dr. Myles Gart, Medical Economics, May 2017

Opioid Prescribing & Opioid-Related Harm

National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System; Treatment Episode Data Set

Where do People get their Opioids?

SAMHSA. (2017). Results from the 2016 National Survey on Drug Use and Health

The Year

Drug Addiction Treatment Act: Congress ActsAllowed prescription of medication to treat opioid addiction from the primary care doctor’s office

Additional training to get the DATA waiver to prescribe buprenorphine

BIG change from NATA of 1974 allowing only daily dosing clinics to dispense methadone for the treatment of addiction.

Buprenorphine, relatively new medication, billed as less likely to be abused, and more difficult to overdose.

From ACOPC Summer Conference 2016 slides and product websites.

The Early 2000s

The internetSo much potential for sharing information and perspectives

Has been shown to be isolating in the way many Americans are using it for social media, leading to increased rates of depression, inadequacy, lack of connection and perspective.

Happiness vs. PleasureHappiness: a state of well-being and contentment

Pleasure: a state of gratification (Merriam Webster)

The search for happiness?

Reasons for Prescription Opioid Misuse

SAMHSA. (2017). 2016 NSDUH.

2010- present

Opioid Overdose & Prescribing Trends

CDC 2018, Pezalla et al. 2017.

Social pressures

“Many factors contribute ... including family and social relationships, social-emotional development, early childhood trauma and lack of economic opportunity, poor working conditions and eroded social capital in depressed communities...”

-- Trust For America’s Health National Resilience Strategy. 2018. https://www.tfah.org/report-details/pain-in-the-nation/

Multi-layered epidemic in 3 waves

https://www.vivitrol.com/opioid-dependence/about-addiction-and-treatment

Advances in neuroscienceNeuroplasticity: ability of brain to alter the strength of connections among neurons, effectively re-wiring them and create entirely new pathways.

Brain is resilient:

Neuroplasticity occurs through life cycle!

Treatment CAN be effective

Epigenetics“Changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself.”

Individuals respond to their unique environment based on individual genotype.

Gene by environment interactions.

Can occur in both positive and negative directions.

What we are doing that is working

To effect supply and demandAcademic detailing of physicians to counter marketing from drug companies

Regulation, opioid prescribing guidelines

Education of people about dangers of opioid use, alone and with other substances

To increase treatment Education of providers, medical students, residents about addiction

Peer Recovery Coaches

Law enforcement and mental health partnerships to access treatment- drug court diversion programs

Talking about addiction as a disease

Harm reduction works!

Reducing Stigma campaigns

Treatment lessonsNeed fewer barriers to access treatment: ACA, Medicaid expansion

Treatment needs to be individualized, and timely

Treatment needs to be available at the time of discharge from jail, institutional settings

Treatment works best when physicians and patients decide how long a medication and therapy are continued.

From https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

November 25, 2018

Opposite of Addiction:

ConnectionImage from https://www.huna.org/html/hcircle.html

Future Opportunities

Clinical changes already happening!

Clinical guidelines that specify limited indications for prescribing opioidsEvidence based alternatives to treat painChange measurement of pain from a number to functionPDMP for all prescribers, including dentists

Opportunities“We need a comprehensive National Resilience Strategy that focuses on prevention, early identification of issues and effective treatment.”

Individual

Family

City and State

Federal

Trust For America’s Health National Resilience Strategy. 2018. https://www.tfah.org/report-details/pain-in-the-nation/

IndividualBe aware of the difference between happiness and pleasure

Find ways to calm yourself that are healthy and connect you to things you find meaningful

Question advertising messages

Explore resources like www.storyofstuff.com; Campaign for Commercial Free Childhood

IndividualKeep your medications safe and accountable

Learn how to use Narcan- no prescription required in Wisconsin

Allow yourself to get help if you need it- there are resources available

Be realistic about expectations of pain management

Look for multi-modal ways to relieve pain

Try being non-judgmental

From https://www.originsrecovery.com/together-can-fight-powerful-stigma-addiction/

FamilyFocus on the impact on children and need for multi-generational approach

Eat dinner together as much as you can

Talk to each other about things that matter to you

Let the kids in your life know how you feel about substance use early.

Talk about family history of substance use so kids know their risk factors

Help kids thrive without as much media in their lives (yes, this takes more of your time)

Celebrate holidays with time together rather than things

City and State: increase community resilienceHelp community be more connected

Invest in early childhood programs

Support children’s education and access to mental health care at all grade levels

Remove silos of care, encourage sharing treatment opportunities

Support different treatment approaches- therapeutic communities, treatment and employment support in one place

Expand life-skills training in areas that are economically distressed

StateSupport easier access to health care, not just health insurance

Regulate direct to consumer marketing of drugs

Achieve parity and integration of mental health care into primary care provider offices

Harm reduction programs: Needle exchange, fentanyl test strips

Support education and campaigns to reduce stigma

Support meaningful employment, stable housing

FederalBan marketing of opioids, stimulants and sedatives.

Update laws regarding treatment with methadone

Easier access to health care, not just insurance

Policies that prevent despair and support growth

Fraser M (2019). The Opioid Epidemic’s Prevention Problem. AJPH: 109: 2, 215-217.

An interesting comparison . . .

First Opioid Epidemic (early 1900s)

Preceded by Industrial Revolution

Loss of jobs, economic instability

The Great Depression

Corporate marketing, increased drug use

Congressional Regulation

The New Deal

This Opioid Epidemic

Technological/ information Revolution

Loss of jobs, economic instability PLUS climate crisis/ anxiety

The Great Recession

Corporate marketing, increased drug use, MORE lethal substances

Congressional Regulation, scientific advances

? ?

Grow your sphere of resilience

Overdoses by Specific Opioid

Source: CDC/NCMS, National Vital Statistics System, Mortality. CDC Wonder, Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2017. https://wonder.cdc.gov

www.cdc.govYour Source for Credible Health Information

Cicero T et al. JAMA Psychiatry. 2014; Cicero T et al. Addict Beh. 2017

Shifting Patterns of First Opioid UsedTreatment Admissions for Heroin Use Disorder

Purity % CostHeroin Purity and Cost

Institute for Defense Analysis and ONDCP