1 1 Wilson M. Compton, M.D., M.P.E. Deputy Director National Institute on Drug Abuse Prevention for an Era of Shifting Drug Use: Opioids, Marijuana, ECigarettes Healthy Heart Diseased Heart Decreased Heart Metabolism in Heart Disease Patient Addiction is a Disease of the Brain as other diseases it affects the tissue function Control Cocaine Abuser Decreased Brain Metabolism in Drug Abuse Patient Sources: From the laboratories of Drs. N. Volkow and H. Schelbert High Low Many Factors Lead to Drug Abuse and Addic�on Addic�on DRUG Brain Mechanisms Biology/Genes John Smith James Smith Ann Jones John Jones Mary Hill Walter Jones James Hill Susan Adams Alice Price Thomas Jones William Price Richard Hill Steven Adams Allison Fields Mary Walters Alice Benson Rebecca Wilson ThomasSmith John Smith EdwardSmith AnneCook JaneWalker John Walker JaneJones Susan Edwards JamesCook Beth Bryson JonathanCook Edward Bryson Amy Mason Beth Carter Environment • Prevention Approaches Should Enhance Protective Factors & Reduce Risk Factors Reduce these Elevate these How Prevention Interventions Work MODIFIABLE RISK and PROTECTIVE FACTORS Background Factors Age Gender Race/ethnicity Poverty level Genotype Early aggression Social skills deficits Academic problem Misperceived drug use norms Association with deviant peers Neighborhood availability Media glamorization Parental monitoring and support INTERVENTIONS Parent skills training Social skills training Selfregulation Impulse control Tutoring Norms training Refusal skills Community policing Health literacy Nurse Home Visiting during pregnancy and first two years impacts substance use, mental health and academics Arch Pediatr Adoles Med, 164(5) 412418, 2010 Percent of Children Who UsedTobacco, Alcohol, or Marijuana (Last 30 Days) Child Age 12 Percent of Children with Internalizing Problems (Borderline or Clinical) Child Age 12 0 1 2 3 4 5 6 Nurse Comparison 0 1 2 3 4 5 6 Nurse Comparison PIAT Scores Reading & Math – Age 12 (Born to LowResource Mothers) 80 85 90 Nurse Comparison Percent of Mothers with Role Impairment due to Alcohol or Drug Use – Child Age 12 0 1 2 3 Nurse Comparison
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Wilson M. Compton, M.D., M.P.E. Deputy Director
National Institute on Drug Abuse
Prevention for an Era of Shifting Drug Use:
Opioids, Marijuana, E-‐Cigarettes
Healthy Heart Diseased Heart
Decreased Heart Metabolism in Heart Disease Patient
Addiction is a Disease of the Brain as other diseases it affects the tissue function
Control Cocaine Abuser
Decreased Brain Metabolism in Drug Abuse Patient
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
Early aggression Social skills deficits Academic problem
Misperceived drug use norms Association with deviant peers Neighborhood availability
Media glamorization Parental monitoring and
support
INTERVENTIONS
Parent skills training Social skills training
Self-‐regulation Impulse control
Tutoring Norms training Refusal skills
Community policing Health literacy
Nurse Home Visiting during pregnancy and first two years impacts substance use, mental health and academics
Arch Pediatr Adoles Med, 164(5) 412-‐418, 2010
Percent of Children Who Used Tobacco, Alcohol, or Marijuana (Last 30 Days)
Child Age 12
Percent of Children with Internalizing Problems (Borderline or Clinical)
Child Age 12
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Nurse Comparison0
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Nurse Comparison
PIAT Scores -‐ Reading & Math – Age 12 (Born to Low-‐Resource Mothers)
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Nurse Comparison
Percent of Mothers with Role Impairment due to Alcohol or Drug Use – Child Age 12
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Nurse Comparison
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PROSPER (Community/University Partnership) Reduces Illicit Substance Use
Sum of six lifetime illicit use measures (methamphetamines, Ecstasy, inhalants, Vicodin, prescription drug misuse overall, other illicit drug use); Intervention vs. Control difference in slope is statistically significant, as are differences at multiple time
points, including 11th and 12th grades.
Reduced Increase in Use Through 6½ Years Past Baseline
Source: Spoth, Redmond, Shin, Greenberg, Feinberg, et al. (2013). PROSPER community-‐university partnerships delivery system outcomes through 6½ years past baseline.
Higher Risk = Lifetime initiation of alcohol, cigarette or marijuana use at baseline; Lower Risk = No initiation at baseline.
Intervention effects are significantly stronger for the Higher-‐Risk subgroup, as compared to the Lower-‐Risk Subgroup.
Greater Impact of PROSPER on High Risk Youth Through 6½ Years Past Baseline
PROSPER (Community/University Partnership) Reduces Illicit Substance Use
Source: Spoth, Redmond, Shin, Greenberg, Feinberg, et al. (2013). PROSPER community-‐university partnerships delivery system outcomes through 6½ years past baseline.
Interventions Can Influence the Behaviors of Nonparticipants Through Friendship Networks
Adolescents with 3+ friends participating in the Strengthening Family Program were less likely to use cigarettes or get drunk than those who had no friends in the program (3 yrs post intervention).
Effects primarily diffused through friendship networks by reducing unsupervised time with friends, changing friends’ attitudes about SU, and then changing nonparticipants attitudes about SU.
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baseline post-‐test 1 yr FU 2 yr FU 3 yr FU
% Repor�n
g An
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onth
Drunkeness
0 SFP friends
1 SFP friend
2 SFP friends
3+ SFP friends
interven�on implemented
Kelly et al., J Adolesc Health 2015
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interven�on implemented
Preven�ve Interven�ons Can Have Long-‐term Effects on Drug
Use and Abuse
Responding to Shifting Drug Use and Policy Environments
MARIJUANA: The shifting legal landscape suggests possible population impacts
E-‐CIGARETTES: Both potential promise for established tobacco users and concern for increasing adolescent use
OPIOIDS: Impacts on public health in the USA starting with over-‐exposure to prescription opioids
2013 OD Deaths: 16,235 Rx opioid
– (16,917 in – )
8,257 Heroin – (4,397 in 2011)bb
Slight Reductions in Rx Opioid-‐Related Deaths but Marked Increases in Heroin
Sources: National Vital Statistics System, CDC
– (16,007 in 2012 and 16,917 in 2011)
– (5,927 in 2012 and 4,397 in 2011)
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Overall Increases in Deaths in 45-‐54 Year Old, White, Non-‐Hispanics in USA (Compared to Others)
U.S. Whites France Germany U.S. Hispanics United Kingdom Canada Australia Sweden
High Rates of Rx Opioid Abuse: 12-‐Month Prevalence of Rx Opioid Misuse, USA Ages 18-‐64,
2003-‐2014
%
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
Increasing Frequent Rx Opioid Misuse: 12-‐Month Prevalence of 100+ days Rx Opioid, USA Ages 18-‐64,
2003-‐2014
% Trend, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
Increasing Rx Opioid Abuse/Depedence: 12-‐Month Prevalence of Rx Opioid Ab/Dep, USA Ages 18-‐64, 2003-‐2014
% Trend, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
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Rx Opioid Use Without 100+ or Ab/Dep
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Increasing Intensity of Opioid Misuse: 12-‐Month Prevalence of Rx Opioid Misuse without Frequent Use or Ab/Dep,
Rx Opioid Ab/Dep, 100+ days Rx Opioid in USA Ages 18-‐64, 2003-‐2014
%Trends, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015 Aug;35(8):667. doi: 10.1038/jp.2015.63. PubMed PMID: 26219703.
Increasing Neonatal Abstinence Syndrome Incidence & Geography, U.S. 2009-‐2012
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Opioids Lead to Infectious Diseases: Outbreak of HIV Linked to
Oxymorphone Injection Drug Use
80% 3%
17% (23)
Injection Drug Use
No Injection Drug Use Not Interviewed to Determine Status
All reported injecting tablets of oxymorphone As drug of choice
84.4% 114 co-‐infected with Hepatitis C
Reported average of 9 syringe-‐sharing partners, sex partners, or other social contacts at risk for HIV infection contacts
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162 HIV Infections in Indiana Community of 4200
61.7%
4.6%
247 located
47% 53%
109 121 HIV-‐ HIV+
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230 tested
128 not located
57.8% 42.2%
74 54
syringe-‐sharing or sex partners
social contacts regarded as at high risk for HIV
Similarities of Illicit & Prescription Opioids
Prescription Opioids Before Heroin: Shifting Pattern of Heroin v. Rx Opioid First
Percentage of Heroin-‐Addicted Treatment Admissions that Used Heroin or Prescription Opioid as First Opioid
Source: Cicero et al. JAMA Psychiatry. 2014;71(7):821-‐826
1960s: more than 80% started with heroin. 2000s: 75% started with prescription opioids. 2010-‐2013: Increasing initiation with heroin
Marked Increases in Heroin: Past Year Heroin Use, Persons Aged 12+, 2003-‐2014
Ø Expanded use of medication-‐assisted-‐treatment (MAT) for opioid use disorders
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How Can NIH/NIDA Research Help?
PAIN: Less Abusable Analgesics and Alternative Therapeutics OVERDOSES: User Friendly Naloxone PREVENTION: Universal Prevention ADDICTION: New Medications and Immunotherapies IMPLEMENTATION SCIENCE: Greater Use of Evidence
Near Tripling of Opioid Prescriptions Dispensed by U.S. Retail Pharmacies, Years 1991-‐2013
IMS Health, Vector One®: National, Years 1991-‐2011, Data Extracted 2012 IMS Health, National Prescription Audit, Years 2012-‐2013, Data Extracted 2014
More than One Clinician (2.6%)
1Other category includes Wrote Fake Prescription," "Stole from Doctor’s Office/Clinic/Hospital/Pharmacy," and "Some Other Way."
Free from Friend/
Relative (53.0%)
Bought/Took from Friend/Relative
(14.6%)
Drug Dealer/ Stranger (4.3%)
Bought on Internet (0.1%)
Other1 (4.3%)
One Clinician (21.2%)
Source Where Respondent Age 12+ Obtained Analgesics:
Free from Friend/Relative
(5.1%) Bought/Took from
Friend/Relative (4.9%)
Drug Dealer/ Stranger (1.4%)
One Clinician (83.8%)
More than One Clinician
(3.3%)
Bought on Internet (0.3%)
Other1 (1.2%)
Source Where Friend/Relative Obtained
People Abusing Analgesics DIRECTLY & INDIRECTLY Obtain Them by Prescription: Most Recent Pill Source
Source: SAMHSA, 2012 and 2013 National Survey on Drug Use and Health
Opioid Prescribing Guidelines
Ø Intended for primary care providers Ø Will apply to patients >18 years old in chronic pain
outside of end-‐of-‐life care Ø Builds on joint CDC, NIDA, ONC, SAMHSA summary
on “Common Elements in Guidelines for Prescribing Opioids for Chronic Pain” and the NIH Pathways to Prevention for Opioids in Treating Chronic Pain
Ø Planned for publication in January 2016
Ø Current Landscape for Guidelines: § Small Number § Outdated § Not Conflict Free
Ø Solution….
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
Decline in Drug Overdose Deaths After State Policy Changes in Florida, 2010–2012
Semi-Annual Drug Overdose Death Rates* for Selected Drugs, & Selected Prescription Drug Diversion & Misuse Actions Taken, Florida, 2006 – 2012+
*Per 100,000 population. Based on Florida Department of Health resident population estimates. + The source of overdose death data is the Florida Medical Examiners Commission.
Source: CDC, MMWR Vol 63, July 1, 2014.
A. 1/4/2010—Pain clinics must register B. 2/2010—Operation Pill Nation C. 10/1/2010—Pain clinic regulation D. 2/23/2011—Operation Pill Nation—raids E. 7/1/2011—Physician dispensing prohibited & statewide regional strike forces F. 9/1/2011—Mandatory PDMP reporting G. 7/1/2012—Wholesale regulations
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Hydrocodone Declines (22%) 2014 to 2015: Opioid Analgesic Prescriptions Dispensed from US Retail
Pharmacies for Select Opioids Q4-‐2009 to Q2-‐2015
30,088,966
23,384,486
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Q4 2009
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Num
ber o
f Prescrip
�ons Dispensed
hydrocodone oxycodone tramadol morphine fentanyl
Source: CM Jones. NIDA Webinar 9/1/2015. Based on IMS Health National Prescription Audit (extracted 8/24/2015) Retrieved from http://www.drugabuse.gov/news-‐events/meetings-‐events/2015/09/latest-‐prescription-‐trends-‐controlled-‐prescription-‐drugs.
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Universal Drug Abuse Prevention Reduces Prescription Drug Misuse
Notes: General=Misuse of narcotics or CNS depressants or stimulants. Source: R Spoth et al. American Journal of Public Health 2013
In this study, for 100 young adults in general population starting Rx abuse, only 35 young adults from an intervention community started.
** p<.01;
Overall, three studies now suggest the impact of universal prevention on prescription drug abuse.
15.5%
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12%
16%
Age 25 General Age 25 Opioids
Control Family Program
Another Key Emerging Drug Issue in the USA: Status of Marijuana Laws in the USA
