The Jungle of Opioids. Tim Short, MD, FAAFP, FAAHPM Associate Professor, Palliative Medicine University of Virginia

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1 The Jungle of Opioids Tim Short, MD, FAAFP, FAAHPM Associate Professor, Palliative Medicine University of Virginia

2 The Balancing Act More Americans suffer from uncontrolled pain than heart disease, diabetes, and cancer combined. Meghani, Pain Medicine 2012; 13:5-28 How do we balance the provision of adequate access to opioids for the treatment of pain with the growing problem of prescription drug abuse?

Rate* of unintentional drug overdose deaths United States 1970 2007 * Per 100,000 population. Source: National Vital Statistics System.

3 Rate* of unintentional drug overdose deaths United States * Per 100,000 population. Source: National Vital Statistics System. Available at In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes.

4 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: Where do they obtain opioids? Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings

5 Opioid Epidemic in Virginia 2014: more people died of opioid overdoses than car accidents November 2016: Governor Terry McAuliffe declared the Virginia opioid addiction crisis a public health emergency. ED visits for heroin overdoses were up 89% in 2016 compared to 2015

6 The Bottom Line on Misuse/Diversion/Abuse From the Physician s Perspective If a clinician has the slightest inkling that a patient presenting with severe pain has an ulterior motive for wanting pain control interventions, the clinical encounter becomes a no win scenario from the clinician s perspective. If he prescribes an opiate, he ll be staring at the ceiling in the middle of the night wondering if the opiate is being sold on the street. If the clinician doesn t prescribe an opiate, he ll be staring at the ceiling wondering if he caused a patient to needlessly endure ongoing pain. Paul Grossman, MD, family physician

7 Addiction versus Substance Abuse What s the Difference? Other important terms: Abuse (Misuse is a better term) Intoxication Physical Dependence and Withdrawal Tolerance What makes any substance psychoactive? Or reinforcing? Or addicting? Increasing Dopamine in the forebrain

8 Higher Brain A A=Addiction P P=physical tolerance, withdrawal

9 SUBSTANCE ABUSE the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological (or social or occupational) problem that is likely to have been caused or exacerbated by the substance.

10 ADDICTION the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological (or social or occupational) problem that is likely to have been caused or exacerbated by the substance.» AND persistent desire or unsuccessful efforts to cut down or control substance use.

11 Addiction Repeatedly doing something which is BAD for you (not just bad) Cannot stop doing it without help IT ALL COMES DOWN TO FUNCTIONING!!!!!!!!

12 HOW DO YOU KNOW IF A HUMAN HAS ADDICTION? WILL CHOOSE THE SUBSTANCE INSTEAD OF: TAKING CARE OF THEMSELVES, THEIR FAMILIES, THEIR RELATIONSHIPS AND THEIR LIVES CAN T STOP WITHOUT HELP

13 PART 2: EXPOSURE TO SUBSTANCES WHAT MAKES A SUBSTANCE ADDICTIVE? ELEVATES DOPAMINE IN THE FOREBRAIN FAST HIGH THE FASTER AND THE HIGHER, THE MORE ADDICTIVE A SUBSTANCE IS

14 Heroin, cocaine, IV Dilaudid, Nicotine, Snorted/Injected Oxycontin (old formulation), Xanax Increase in dopamine Percocet, Immediate Release Morphine, Higher Proof Liquor, non-injected Oxycontin, Vicodin Abused Methadone, Abused Buprenorphine, Lower Proof Alcohol, Marijuana Rate of increase, fast to slow Methadone, Buprenorphine taken as directed

15 Street Value 100 Oxycontin 80mg (old formulation ) $8-16, Dilaudid 8mg $8-10, Xanax 2mg $1, Vicodin $500-$800 4 Fentanyl patches 100ug $400 Methadone 1$ per milligram Percocet 10mg $32/pill Suboxone 8/2 strip $25 * Beard, J Tobias, Coke is the Real Thing; Fifty bucks and you re in with Charlottesville s favorite powder, C VILLE CHARLOTTESVILLE NEWS & ARTS, 2/11/2008

16 Non-controlled substances with street Muscle Relaxants Remeron HIV medications Prednisone Neurontin Seroquel ULTRAM!!!!!!!!! value It s not about the Substance. It s about the Brain.

17 Treating Addiction ADDICTS ARE THE MOST VULNERABLE POPULATION IN HEALTH CARE!!!!!!!!! ASHAMED DESPERATE WILL PAY ANYTHING JUST TO MAKE IT GO AWAY.

Buprenorphine/Naloxone Maintenance Treatment for Opioid Dependence

Buprenorphine/Naloxone Maintenance Treatment for Opioid Dependence Information for Family Members Family members of patients who have been prescribed buprenorphine/naloxone for treatment of opioid addiction