Overview of the Opioid Analgesic Epidemic

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1 Overview of the Opioid Analgesic Epidemic Putnam County, MD September 14th, 2012, Andrew Kolodny, M.D. Chair, Department of Psychiatry Maimonides Medical Center Brooklyn, New York

2 Presentation Outline I. Past opioid epidemics II. Current epidemic III. Reasons for the current epidemic IV. The chronic pain controversy V. Strategies to control the epidemic

3 The Opium Poppy Papaver Somniferum

4 The Opium Poppy Papaver Somniferum

5 Crude Opium Latex on Poppy Head

6 Opioids Morphine Codeine Heroin Hydrocodone (Vicodin, Lortab) Methadone Oxycodone (Percodan, Oxycontin) Hydromorphone (Dilaudid) Meperidine (Demerol)

7 In 1804, Frederich Serturner isolated an alkaloid base from opium which he called Morphium (after the Greek god of sleep and dreams, Morpheus).

8 Winslow's Soothing Syrup for infants Active Ingredient: Morphine

10 1889 Opinion Survey of 180 Druggists in Massachusetts regarding economic/social status of opioid-addicted customers Opioid-addicted customers are from All classes 22% The upper class 22% The middle class 3% The lower class 6% The Sale and Use of Opium in Massachusetts, 1889 Annual Report of the Massachusetts Board of Health, as reported in The American Disease by DF Musto, 1973

11 THE HYPODERMIC SYRINGE

12 Heroin Discovered in 1878 Synthesized by mixing morphine with acetic anhydride (an acid) and heating up the mixture Bayer s name heroin believed to derive from the German word heroisch Thought to be a non-addictive alternative to morphine

14 Mulberry Street in New York City 1900

15 Harrison Act of 1914 Required all persons who dealt in or prescribed opium or opium derivatives to register with the IRS, pay special taxes and keep records of their transactions Treasury Department (Bureau of Internal Revenue) interpretation was that it was unlawful for a physician to prescribe an opioid to treat addiction

16 Charlie Parker

17 Source: The New York Times Magazine, June 5, 1977

18 Source: New York Magazine, August 14th 2000

19 Prior Opioid Abuse Epidemics 1. Late 1800s: Morphine Mainly middle class Female > Male 2. Early 1900s: Heroin (pharmaceutical grade) First generation Italians, Jews, Irish Male > Female s-1970s- Heroin (illicit) African American/Latinos > White Male > Female

21 Past Year Initiates among Persons Aged 12 or Older: 2007 Source: SAMHSA Office of Applied Studies (2007)

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

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

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

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

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

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

28 80000 Opioid Analgesic Treatment Admissions: U.S Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Highlights National Admissions to Substance Abuse Treatment Services. OAS Series #S-45, HHS Publication No. (SMA) , Rockville, MD, 2009.

29 Characteristics of opioid-addicted, treatment-seeking patients

30 Rates of ED visits for nonmedical use of selected opioid analgesics increased significantly in the US ED visits per 100,000 population * * * * * * 5 0 * * * * Fentanyl Hydrocodone Hydromorphone Methadone Morphine Oxycodone * Indicates a rate that was significantly less than the rate in Note: Drug types include combination products, e.g, combinations of oxycodone and aspirin.

31 Number of of drug-induced deaths deaths compared compared with other with types of deaths, US, other types of deaths, US,

39 Motor vehicle traffic, poisoning, and drug poisoning death rates of all intents, U.S., Source: NCHS Data Brief, December, 2011, updated with 2009 mortality data. Some overdose deaths were not included in the total for 2009 because of delayed reporting of the final cause of death. The reported 2009 numbers are underestimates. 39

40 Overdose deaths of all intents by major drug type, U.S., Number of deaths 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Opioid analgesic Cocaine Heroin Source: National Vital Statistics System 40

41 Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., Number of Deaths '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 * Opioid sales (mg/person) Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary.

42 Drug overdose deaths of all intents by type of opioid involved, US, Number of deaths 12,000 10,000 8,000 6,000 Hydrocodone, oxycodone, morphine, codeine, hydromorphone, et al. Methadone 4,000 2,000 0 Fentanyl, meperidine, propoxyphene, buprenorphine, et al Some overdose deaths were not included in the total for 2009 because of delayed reporting of the final cause of death. The reported 2009 numbers are underestimates.

43 Unintentional Drug Overdose Deaths United States, ,450 drug overdose deaths in Death rate per 100, Heroin Cocaine 1 0 '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 Year National Vital Statistics System, 43

45 Heroin Treatment Admissions: Age & Race,

48 Dollars Spent Marketing OxyContin ( ) Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion and Efforts to Address the Problem.

49 Total Sales & Prescriptions for OxyContin ( ) Source: United States General Accounting Office: Dec. 2003, OxyContin Abuse and Diversion and Efforts to Address the Problem.

51 Industry-influenced Education on Opioids for Chronic Non-Cancer Pain 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.

52 Only four cases of addiction among 11,882 patients treated with opioids. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med Jan 10;302(2):123 Cited 693 times (Google Scholar)

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

55 Heroin compared to prescription opioids Peak ratings for I feel high similar for heroin, morphine and oxycodone. Subjects willing to pay $10-15 for highest dose of heroin, morphine and oxycodone. Buprenorphine had highest I feel bad drug effect. Comer et al. Abuse Liability of Prescription Opioids Compared to Heroin in Morphine-Maintained Heroin Abusers. Neuropsychopharmacology (2008) 33,

56 Photo taken at the The 7th International Conference on Pain and Chemical Dependency, June 2007

57 Federation of State Medical Boards Model Policy for the Use of Controlled Substances for the Treatment of Pain Distributed by 21 state medical boards to over 150,000 clinicians. The book s sponsors include: Abbott Laboratories Alpharma Pharmaceuticals LLC Cephalon, Inc. Endo Pharmaceuticals King Pharmaceuticals Purdue Pharma L.P. Federation of State Medical Boards House of Delegates, May Accessed March 2010.

58 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 FRCA Professor, Univ. of Washington Source: New York Times, April 9, Tightening the Lid on Pain Prescriptions.

59 The Emperor s New Paradigm: Patient Selection, Risk Stratification & Monitoring

60 Clozapine vs Opioids Comparison of methods for preventing serious adverse events Clozapine for Schizophrenia Opioids for Chronic Pain Evidence-Based Treatment Yes No Adverse Event (AE) Risk(%) Agranulocytosis 1% Addiction 25% Routine lab monitoring Weekly WBCs Urine Toxicology Monitoring can prevent AE Yes No Patient Registry Yes No

61 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):

62 Controlling the epidemic: A Three-pronged Approach Primary Prevention- prevent new cases of opioid addiction. Secondary Prevention- provide people who are addicted with effective treatment. Supply control- collaborate with law enforcement, DEA and OPMC to overprescribing and black-market availability.

63 Develop and Implement a Standard of Care Opioid Prescribing in 2012-The Wild West

64 Opioid Prescribing Rules Require urine toxicology for all patients receiving longterm opioid therapy. Require a physical exam and documentation that alternative treatments have failed. Set dosing limits to prevent high dose prescribing. Require screening for addiction before & during treatment. Require screening for depression before initiating therapy. Mandate training in pain and addiction.

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

66 FDA permits drug manufacturers to advertise opioids as safe and effective for chronic pain.

67 Summary The United States is facing a public health crisis fueled by overprescribing of opioids. Prescribers and the public need to be better informed about risks of opioid use/misuse. Interventions to bring this epidemic under control are within our grasp.

68 Please visit:

The Prescription Opioid and Heroin Crisis: An Epidemic of Addiction

The Prescription Opioid and Heroin Crisis: An Epidemic of Addiction Andrew Kolodny, M.D. Chief Medical Officer, Phoenix House Foundation Inc. Executive Director, Physicians for Responsible Opioid Prescribing