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