Responding to the Opioid Addiction Epidemic

Andrew Kolodny, M.D.Chief Medical Officer

Phoenix House FoundationNew York, NY

The Opium PoppyPapaver Somniferum

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Crude Opium Latex on Poppy Head

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Opioids• Morphine • Codeine• Thebaine• Diacetylmorphine (Heroin)• Hydrocodone (Vicodin)• Oxycodone (Oxycontin)• Oxymorphone (Opana)• Hydromorphone (Dilaudid)

Naturally occurring opioids- also called opiates

Semi-synthetic opioids

Prior Opioid Addiction Epidemics1. Late 1800s: Morphine

• Mainly middle class• Female > Male

2. Early 1900s: Heroin (pharmaceutical grade)• First generation Italians, Jews, Irish• Male > Female

3. 1950s-1970s- Heroin (illicit)• African American/Latinos • Male > Female

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Governor Shumlin devotes entire state of the state speech to Vermont’s opioid addiction epidemic

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1

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5

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'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

De

ath

rate

pe

r 1

00

,00

0

HeroinCocaine

38,329 drug overdose deaths in 2010

Unintentional Drug Overdose DeathsUnited States, 1970–2007

National Vital Statistics System, http://wonder.cdc.gov

Year

Drug Overdose Deaths by Major Drug Type,

United States, 1999–2010

CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Opioids Heroin Cocaine Benzodiazepines

Year

Num

ber

of

Death

s

Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

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Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011

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Heroin admissions, by age group & race/ethnicity: 2001- 2011

Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year,

U.S., 1997-2007

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100

200

300

400

500

600

700

800

0

2000

4000

6000

8000

10000

12000

14000

'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07

Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS* 2007 opioid sales figure is preliminary.

Number of

DeathsOpioid sales (mg/person)

*

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

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Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000

Year

Rate

Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010

CDC. MMWR 2011

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Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and Efforts to Address the Problem.”

Dollars Spent Marketing OxyContin (1996-2001)

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.

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Industry-funded organizations campaigned for greater use of opioids

• Pain Patient Groups

• Professional Societies

• The Joint Commission

• The Federation of State Medical Boards23

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)

“The risk of addiction is much less than 1%”

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N Engl J Med. 1980 Jan 10;302(2):123.

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“I think that after 20 years of a failed experiment that there are not many people supporting this except for the die-hards and the pharmaceutical industry.”

Jane C. Ballantyne, MD FRCAProfessor, Univ. of Washington

Source: New York Times, April 9, 2012. “Tightening the Lid on Pain Prescriptions”.

The Emperor’s New Paradigm:

Patient Selection, Risk Stratification & Monitoring

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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.

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Controlling the epidemic:A Three-pronged Approach

• Prevent new cases of opioid addiction.

• Treatment for people who are already addicted

• Supply control- Medical board & law enforcement efforts to reduce over-prescribing and black-market availability.

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Opioid manufacturers continue to advertise opioids as safe and effective for chronic pain.

How the opioid industry Frames the Problem

Source: Slide presented by Lynn R. Webster MD at FDA meeting on hydrocodone upscheduling, January 25th, 2013.

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Drug overdose death rates by intent by age group, US, 2008

Pain Patients “Drug Abusers”

63% admitted to using opioids for purposes other than pain1

35% met DSM V criteria for addiction2

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.

This is a false dichotomy Aberrant drug use behaviors are common in pain patients

92% of opioid OD decedents were prescribed opioids for chronic pain.

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.

Frequently Discussed Interventions

• Abuse-deterrent formulations• Expanding access to naloxone• Expanding access to medication assisted

treatment• PDMP-based interventions• Mandatory prescriber education

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Buprenorphine Treatment

• Partial agonist– Weaker effects– Safer to use

• Long duration of action

• Milder withdrawal symptoms

 

Full Opioid Agonists

Buprenorphine- A Partial Agonist

Summary

• We are in the midst of the worst drug epidemic in U.S. history.

• To end the epidemic we need to:– PREVENT new cases of opioid addiction– TREAT people who are already addicted

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www.supportPROP.org

Please visit

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@andrewkolodny