The Opioid Scourge

NOUN: A PERSON OR THING THAT CAUSES GREAT TROUBLE OR SUFFERINGSYNONYMS: AFFLICTION, BANE, CURSE, MENACE, BURDEN, EVIL

DR. CAROLINE CARNEYCHIEF MEDICAL OFFICER

1,000,000,000,000

72,00049,000

1

$1,000,000,000,000economic toll on the United States

since 2001

https://altarum.org/about/news-and-events/economic-toll-of-opioid-crisis-in-u-s-exceeded-1-trillion-since-2001

201772,000 drug fatalities

49,000 deaths from opioids In comparison

• 58,000 US soldiers died in the entire Vietnam War

• 37,500 Americans died of motor vehicle accidents in 2016

• 609,640 women, men and children will die from all types of cancer in 2018

• More than 43,000 died due to HIV/AIDS during that epidemic's peak in 1995

• Nearly 40,000 died of guns during the peak of those deaths in 1993

www.CDC.Gov 2017 report of provisional 2017 data National Center for Health Statistics

1One death

of a mother, father, sister, brother, son, daughter, husband, wife, partner

friend, colleague, neighbor, student, workerto irrevocably change the lives

of those living through all the days that follow

Today’s talk

• The money

• The mortality

• The why

• The real story

https://altarum.org/about/news-and-events/economic-toll-of-opioid-crisis-in-u-s-exceeded-1-trillion-since-2001

10

11

This is your brain on drugs

OR WHY IT ISN’T EASY TO BEAT THE OPIOID CRISIS

13

Biology/Genes Environment

Genetics Gender

Mental disorders Chaotic home and abuse Parent’s use and attitudes

Peer influences Community attitudes Poor school achievement

Route of administration • Effect of drug •

Early use • Availability • Cost

Children’s earliest

interactions within the family are crucial to their healthy development and

risk for drug use.

Brain Mechanisms

Addiction8

14

Neurology 101

15

Where addiction happens

16

Dopamine, pleasure, dependence, and addiction

17NIDA, 2017

Neurobiology (continued)

• Over time the opioid receptors in the VTA become less sensitive to dopamine, whether made naturally, or released because of opioids

• More opioids are needed to achieve the same amount of pleasure—even usual pleasurable activities in life no longer feel good

• This is called tolerance—taking the same amount or more to feel the same effect

• Dependence—physiologic adaptation to an opioid, the absence of which leads to withdrawal

• Addiction– the drive to keep taking the drugs—the behaviors and lack of insight

• Craving and withdrawal symptoms reinforce the need to keep taking opioids

20

Addiction

is what turns a soccer mom into a

heroin addict

How do opioids kill?

https://www.statnews.com/2016/09/29/why-fentanyl-is-deadlier-than-heroin/

Why Not Seek Help?

• Shame

• Fear of loss

• Social stigma

• Addiction itself

• Opioid withdrawal syndrome

• Access to Medication Assisted Treatments (Suboxone)

• Access to psychosocial care

• The wrong provider

The wrong provider

24

In your own back yard. . .

25

In the Western District of Pennsylvania, four defendants – all physicians – were charged in various health care fraud and drug diversion schemes. One scheme involved 32,000 dosage units of buprenorphine.

Nationally, at least 1,350 of 12,780 buprenorphine doctors have been sanctioned for offenses that include excessive narcotics prescribing, insurance fraud, sexual misconduct and practicing medicine while impaired.

New York Times, November 2013

The Perils of Predatory Treatment: Rehab Centers

Patient BrokeringPredatory Web Practices Urinalysis Abuse Up-charging and Overutilization Out of Network Schemes KickbacksClinical Misrepresentations Paid Call Center/Directory/Call Aggregation

28

Research evidence shows that inpatient rehabilitation is not superior to outpatient programs

Scenario 1: The opioid deaths forecast for 2027 is 93,613. The forecasted change is 183% since

2015 when it was 33,091. This curve assumes total drug overdoses climb at the same rate they

have for decades. It’s also based on the assumption opioid deaths keep making up roughly the

same percentage of all drug deaths. NATALIA BRONSHTEIN/STAT, 2018

Worst Case Scenario

HOPE

Oft expectation fails,and most oft there where most it promises

and oft it hit where hope is the coldestand despair most fits

30

William Shakespeare, 1833

Best Case Scenario

Scenario 10: The opioid deaths forecast for 2027 is 21,300. The forecasted change

is -36% since 2015 when it was 33,091. This curve assumes doctors prescribe fewer

opioids, states embrace prescription drug monitoring programs, and there are

reforms to increase treatment access and actual quality of treatment. NATALIA

BRONSHTEIN/STAT, 2018

Medication Assisted Therapy (MAT)

• Evidence-based treatment for opioid addiction

• Suboxone, Vivitrol and Methadone

32

Prevention: It makes (dollars) and sense

• Benefit-per-dollar cost ratios for evidence-based interventions range from small returns per dollar invested to more than $65 every dollar invested

• Dose and duration limits

• Education on the treatment of acute and chronic pain

• Licensing pain treatment and addiction centers

• Creating policy to prevent payment for predatory treatment practices

• To understand what addiction really is—a brain disease complicated by the social structures in which it occurs

• Seek integration of behavioral and physical health services with addictions—create the team of providers

33

Monitoring the Future national survey results on drug use: 1975-2013: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.

Addiction is a chronic disease

34

35

Google Blocks Predatory Drug Rehabs from Buying

Anymore Ads

The opioid addiction epidemic in America, which killed more

than 53,000 people in 2016, has fueled the drug treatment

industry's growth, with rehabs and drug treatment facilities

popping up all over the country. But the $35 billion treatment

industry is plagued with untrustworthy facilities that have

learned how to game Google search results. Many drug

treatment centers have mastered SEO practices and buy ad

words on Google to make sure their business appears first

when an addict, or desperate family member, types "drug

treatment center" or "rehab" into the search bar, doctors and

public health experts say.

https://www.inc.com/will-yakowicz/google-restricts-ad-sales-to-drug-treatment-rehab.html

Tenets of treatment

• The best care occurs in the least restrictive environment necessary

• The best care occurs in the community in which the patient lives

• The best care occurs when the patient and their family system are actively engaged and thoroughly informed about all aspects of their care, and are as involved as possible

• The best care occurs when the treatment team actively partners with the health plan and health system, including primary care, specialty care, and behavioral health providers

36

What’s ahead?• Naloxone distribution

• (More) prescribing limitations

• Needle exchange programs

• Screening programs for Hep C, HIV/AIDS

• Precision medicine for prescribing

• Coverage of medications for Hepatitis C and HIV/AIDS

• Policy decisions that promote access to quality care

• Policy decision to prevent predatory providers

• What is the role of law enforcement? Public health?

• How do privacy rules affect identification and treatment?

• What is the role of education?

37

The Real Story

1One death

of a mother, father, sister, brother, son, daughter, husband, wife, partner

friend, colleague, neighbor, student, workerto irrevocably change the lives

of those living through all the days that follow