Heroin Addiction and Overdose: What Can We Do to Address This Growing Problem? Nora D. Volkow, M.D. Director

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1 Heroin Addiction and Overdose: What Can We Do to Address This Growing Problem? Nora D. Volkow, M.D. Director

2 Illicit Drugs Marijuana Prescription Drug Misuse/Abuse is a Major Problem in the US Current Drug Use Rates in Persons Ages Past Year Nonmedical Use of Psychotherapeutic Drugs Persons Ages Psychotherapeutics Cocaine Hallucinogens Inhalants Heroin Percent Numbers in Millions Source: SAMHSA, 2013 National Survey on Drug Use and Health, 2014.

3 High Levels of Opioid Prescriptions have Facilitated Diversion & Contributed to Overdose Deaths Oxycodone & Hydrocodone Prescriptions Rx Opioid Overdose Deaths 160 Oxycodone (Schedule II) Hydrocodone (Schedule III) 18,000 Total Female Male Millions ,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 4,030 4,400 5,528 7,456 8,517 9,857 10,928 15,597 14,408 14,800 13,723 16,651 16,917 16,007 16, SDI Health, VONA_ _Opioids Schedule II & III Source: CDC Wonder

4 Abuse of Opioid Medications has led to a Rise in Heroin Abuse and Associated Deaths from Overdoses Past Month &Past Year Heroin Use Persons Aged 12 or Older 800 9,000 Heroin Overdose Deaths Total Female Male 8,257 Numbers in Thousands Past Year Past Month 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 1,960 1,842 1,779 2,089 2,080 1,878 2,009 2,088 2,399 3,041 3,278 3,036 4,397 5, SAMHSA, 2012 National Survey on Drug Use and Health, Source: CDC Wonder

5 Respondents Who Endorsed Past-Month Use of OxyContin or Heroin Before and After Introduction of an Abuse-Deterrent Formulation (ADF) Drugs Used to Replace OxyContin After the Introduction of the Abuse-Deterrent Formulation (ADF) Past-Month Abuse Among SKIP Respondents, % ADF Release Heroin OxyContin RAPID Respondents, % Jan-Jun 2009 Jul-Dec Jan-Jun 2010 Jul-Dec Jan-Jun 2011 Jul-Dec Jan-Jun 2012 Jul-Dec Jan-Jun 2013 Jul-Dec Jan-Jun 2014 Drug Selected to Replace OxyContin Cicero TJ and Ellis MS JAMA Psychiatry. Published Online March 11, 2015.

6 Analgesic Mechanisms of Mu Opiate Drugs (Heroin, Vicodin, Morphine) ACC (pain) Accumbens (reward) PAG (pain) Thalamus (pain)

7 How Can Research Help? PAIN: Develop Less Abusable Analgesics and Alternative Therapeutics OVERDOSES: User Friendly Naloxone ADDICTION: New Medications and Immunotherapies Pharmacogenomics (Precision Medicine) Implementation Science

8 Develop Less Abusable Drugs: Prodrugs Problem: changing method of taking opioids i.e., crushing, injecting increases euphoria; abuse Challenge: develop drugs that resist tampering; abuse Research response: oxycodone prodrug Inactive compounds metabolized in the body to produce active drug

9 PAIN: Alternative Therapeutics Non-Medication Strategies for the Treatment of PAIN and ADDICTION Transcranial Magnetic Stimulation (TMS) Left periventricular gray Left sensory thalamus Deep Brain Stimulation (DBS) Stereotaxtic implantation of electrodes that emit electrical stimulation to a targeted neuronal region Transcranial Direct Current Simulation (tdcs) High-Definition transcranial Direct Current Stimulation (HD-tDCS) Gray AM et al., J Pain 2014; 15(3): Morena-Duarte I et al., Neuroimage 2014; 85(3):

10 Improving OD Treatments: Naloxone for Overdose Lay-friendly administration: intranasal naloxone AntiOp, developing disposable naloxone nasal spray. Product could be on the market 2015 Lightlake Therapeutics, conducting clinical trials with intranasal naloxone for binge eating disorder will test this for opioid overdose

11 Improving Implementation of Medication Assisted Treatments: Addiction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Treatment Programs Offering FDA-approved SUD medications 25% 9% 17% 9% 16% 19% Not receiving Methadone, Buprenorphine or Vivitrol 69.4% % OTP patients receiving methadone, buprenorphine, or vivitrol Methadone 26.4% Buprenorphine 3.9% Vivitrol 0.3% Knudsen et al., J Addict Med N-SSATS Data, SAMHSA

12 ADDICTION: New Medications & Immunotherapies Opioid Agonist Treatments Decreased Heroin OD Deaths Baltimore, Maryland, RCT Buprenorphine Implants vs Placebo & Sublingual Buprenorphine/Naloxone Heroin overdoses Buprenorphine patients Methadone patients Challenge: Compliance with daily intake Solution: develop long acting medications Schwartz RP et al., Am J Public Health % of Patients Failing to Exceed Each Possible Criterion of Success Placebo Sublingual Buprenorphine Buprenorphine Implants... Probuphine is designed to release sustained therapeutic drug levels in patients with opioid addiction for up to six months % of Urines Negative (out of 72) for Opioids Across Weeks 1 to 24 Rosenthal RN et al., Addiction 2013;105:

13 Treating Opioid Addiction: Vaccines Antibodies reduce amount of drug in the brain Capillary Blood Flow Vaccine Antibodies Binding sites Capillary Blood Flow Targets drugs, not receptors Brain Brain

14 Implementation Science Strategies that Can Help Address the Dangers of Opioid Overdose and Addiction in the US Responsible Prescribing and Management of Chronic Pain, which requires enhanced Education on Pain and its Treatment Availability of Naloxone Mandatory Addiction Education in Medical, Nursing and Pharmacy Schools

15 National Pain Strategy HHS Secretary should develop a comprehensive, population healthlevel strategy for pain prevention, treatment, management, education, reimbursement and research..." NIH Pain Consortium Centers of Excellence in Pain Education Goal: Improve pain treatment through education

16 NIDA Resources for Medical Students, Resident Physicians & Faculty NIDA CoEs established in 2007 to help fill gaps in medical education curricula related to both illicit drugs and Rx drug abuse Medical schools at CoEs have developed a diverse portfolio of innovative curriculum resources about how to identify and treat patients struggling with SUD

17

18 Opioid Overdose Death Rates Were Reduced In Communities Where Overdose Education & Nasal Naloxone Distribution Program (OEND) Was Implemented Unadjusted Unintentional Opioid-Related Overdose Death Rates Unadjusted Opioid-Related Acute Care Hospital Utilization Rates Walley AY et al., BMJ 2013; Published 31 January 2013.

19 Which Drug is the First Opioid Used in Addicts? Shifting Pattern of Heroin vs. Rx Opioid First Total Sample, % Percentage of Heroin-Addicted Treatment Admissions that Used Heroin or Prescription Opioid as First Opioid ` ` ` ` Prescription Opioid Heroin 1960s 1970s 1980s 1990s 2000s 2010s (n=88) (n=114) (n=214) (n=482) (n=1613) (n=286) Decade of First Opioid Use (No. of Abusers) Source: Cicero et al. JAMA Psychiatry. 2014;71(7): ` ` ` 1960s: more than 80% started with heroin 2000s: 75% started with prescription opioids : Increasing initiation with heroin

20 Age-Adjusted Rates for Drug-Poisoning Deaths Involving Heroin, By Census Region: US Rates for Drug-Poisoning Deaths Involving Heroin, By Selected Age & Race & Ethnicity Groups Deaths per 100,000 population Northeast Deaths per 100,000 population Northeast Midwest South West Non-Hispanic White Non-Hispanic Black Hispanic CDC, NCHS Data Brief, No 190, March CDC, NCHS Data Brief, No 190, March 2015.

21 Possible Consequences of Heroin Use Reported cases/100,000 population Increased Risk of Contracting Infectious Diseases including: HIV/AIDS Hepatitis B and C Incidence of acute hepatitis C by age group, U.S., yrs yrs yrs yrs yrs 60 yrs 0 Source: National Notifiable Diseases Surveillance System (NNDSS), CDC

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