Neil A. Capretto, D.O., F.A.S.A.M. Medical Director Gateway Rehabilitation Center

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1 PRESCRIPTION DRUG ABUSE, HEROIN ADDICTION AND OVERDOSE PREVENTION IN RURAL COMMUNITIES Neil A. Capretto, D.O., F.A.S.A.M. Medical Director Gateway Rehabilitation Center

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3 Number of Deaths from Drug Overdoses and Motor Vehicle Accidents among Pennsylvania Adults Age 20 to 44, 1990 to 2011

4 Pittsburgh Post-Gazette, January 23, 2014

5 Overdose Death Rate, 2007 to 2011 (Number of Accidental Drug Poisoning per 100,000 Population

6 NUMBER OF OVERDOSES BY YEAR - ALLEGHENY COUNTY Year Number of Overdose Fatalities Average of 58 per year

7 Drug overdose deaths increasing in Allegheny County Roberta Lojak holds a high school graduation picture of her daughter Ashley Elder, who died of a heroin overdose in October Lojak is standing in a garden she planted in her daughter's memory. September 27, 2004, Pittsburgh Post-Gazette

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9 IT IS ESTIMATED 48,000,000 AMERICANS AGE 12 AND OLDER HAVE USED PRESCRIPTION DRUGS FOR NON-MEDICAL REASONS NATIONAL INSTITUTE ON DRUG ABUSE

10 Certain groups are more likely to abuse or overdose on prescription painkillers Many more men than women die of overdoses from prescription painkillers. Middle-aged adults have the highest prescription painkiller overdose rates. People in rural counties re about two times as likely to overdose on prescription painkillers as people in big cities. White and American Indian of Alaska Natives are more likely to overdose on prescription painkillers.

11 Prescription painkiller overdoses are a public health epidemic Prescription painkiller overdoses killed nearly 15,000 people in the US in This is more than 3 times the 4,000 people killed by these drugs in Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers. Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.

12 The supply of prescription painkillers is larger than ever The quantity of prescription painkillers sold to pharmacies, hospitals, and doctor s offices was 4 times larger in 2010 than in Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month.

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16 drugfreeamerica.org About one in five teenagers have tried prescription painkillers such as Vicodin and OxyContin to get high, with the pill-popping members of Generation Rx often raiding their parents medicine cabinets, according to a study by the Partnership for a Drug-Free America --picked up from the Associated Press Updated: 1:44 p.m. ET April 21, 2005

17 Reason for Using Prescription Pain Relievers: PATS Attitude Tracking Study: 2005 Easy to get from parents' medicine cabinets--62% Available everywhere--52% They are not illegal drugs--51% Easy to get through other people's prescriptions--50% Teens can claim to have a prescription if caught--49% They are cheap--43% Safer to use than illegal drugs--35% Less shame attached to using--33% Easy to purchase over the Internet--32% Fewer side effects than street drugs--32% Can be used as study aids--25% Parents don't care as much if you get caught--21%

18 ARCOS Retail Drug Distribution by Drug Code for the U.S: Oxycodone Hydrocodone Methadone 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000, Source: DEA

19 As Prescriptions Increase, Emergency Room Reports Have Increased at the Same or Faster rate Number of Prescriptions (in 1000s) Hydrocodone prescriptions emergency Oxycodone prescriptions emergency Source: SAMHSA, DAWN, 2002

20 THE OXYCONTIN DILEMMA To chronic and terminal pain sufferers, relief. To conscientious physicians, an effective alternative for the treatment of pain. To the manufacturer, a marketing success. To pharmacists, fear. To the drug abuser and addict, an instant opioid rush and euphoria or death; To their families, grief. To drug diverters and pill-mill doctors, massive health-care fraud and ill-gotten gains. To some treatment centers, an epidemic. To law enforcement, the latest in a long series of drug problems. To the media, a breaking story.

21 OxyContin Is All These Things Unhappily, OxyContin also has found favor with addicts, who crush the tablets for snorting or dissolve them for intravenous injection, either of which delivers an immediate high dose of oxycodone. As a reflection of its current popularity, sixty 40mg tablets of OxyContin, which retail for about $300, can bring $2,400 on the black market. The 40mg tablet is the most commonly diverted, with addicts entering treatment typically reporting doses of 200 to 300mg a day (although intravenous doses of more then 900mg a day have been reported.

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28 OPANA (oxymorphone) The new King of the Streets? PDR: 2 x oxycodone Streets: 2-3 x oxycodone

29 Zohydro (50mg hydrocodone) Time Release FDA Advisory Committee voted 11-2 against approval No requirement for an abuse deterent formulation This form can be easily crushed then smoked, snorted or injected The next OxyContin?

30 (diacetylmorphine) (C21H23NO5 ) (dope, junk, smack, stamp bag)

31 Heroin Use in Allegheny County by Fiscal Year Data from Pennsylvania Department Of Health Heroin

32 PURER, LESS EXPENSIVE HEROIN In 1995, the Drug Enforcement Administration reported small retail purchases of heroin were 59% pure compared to 37% pure in In 1999 heroin in Philadelphia was reported to be 71% pure. Local law officials in Western Pennsylvania report that much of the heroin in our region is now 70% - 90% pure. This compares to average purity rates of 10% - 15% in the 1980 s.

33 "It's so good. Don't even try it once. intravenous heroin user

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35 YOUNGER, MORE AFFLUENT USERS National surveys of substance abuse strongly suggest that most new users of heroin are young. According to the 1999 National Household Survey on Drug Abuse (NHSDA), a quarter of the new users were under age 18 and 47% were age 18 to 25 at their first use. This trend of young users is confirmed by the 2000 Monitoring the Future Study, a national study of high school students, which found that 10.6% of high school seniors have tried heroin at least once in their lifetime and 1.5% had used it in the past year, resulting in the highest rate of heroin use among 12 th graders since the survey began.

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37 INTRAVENOUS VERSUS INTRANASAL USE Once addicted, many users shift from intranasal use to injecting heroin. Intravenous use produces the quickest rush (seven to ten seconds) while snorting and smoking show effects within 10 to 15 minutes of use.

38 HEROIN Health Hazards Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous abortion, collapsed veins, and infectious diseases, including HIV/AIDS and hepatitis.

39 Opioid/Benzodiazepine Interactions Benzodiazepines are widely prescribed but also widely abused by opioid dependent individuals Benzodiazepines do not generally produce respiratory depression alone These may interact with opioids at the enzyme level but may also produce synergistic pharmacodynamic effects unrelated to metabolism Concomitant use enhances the depressant effects of opioids and increases the risk of fatal overdose

40 Each year in Allegheny County, more people die of accidental drug overdose than die in traffic accidents and homicides, combined. Most overdose deaths are preventable, most are witnessed by someone who can help

41 People Don t Call 911 because. Failure to recognize symptoms of overdose. Need for education Don t know what to do results in delayed or ineffectual response. If illegal drug use: Fear of stigma associated with drug use. Don t want friends, family, neighbors to find out. Fear of Police Involvement. Abandonment is the worst response

42 Why Are People Dying? Overdose Deaths from Opiates are almost entirely preventable Out of 224 deaths in 2010, 175 involved at least one substance that would respond to naloxone. Paramedics use naloxone (Narcan) to immediately reverse the effects of opiate overdose

43 OPIOID ANTAGONISTS Life Savers Relapse Reducers

44 Narcan Administration

45 Narcan? Naloxone? what is it? Narcan, also called Naloxone, is a drug used to counter the effects of opioid overdose, for example heroin or morphine overdose. Opiate receptor sites in the body prefer Narcan. While Narcan is binding to the receptors, the opiate has nowhere to bind to, so the opiate has no effect on the body. Once Narcan wears off (after minutes), the receptor sites will be free and the opiate will bind to them again. It is recommended that 911 be called. If there is still enough opiate in the body to cause an overdose, the person will go back into one. On extremely rare occasions, lung complication can occur due to an allergic reaction to naloxone itself. On the other hand if there is not enough opiate in the body, the person can start experiencing withdrawal symptoms. It is recommended discussing these points when developing an OD response plan. If someone has been given Narcan, they should not try to use again for several hours at a minimum due to possible changes in tolerance which can cause another overdose.

46 Narcan reversing an overdose

47 Administering naloxone Nasal: Spray half of the vial of naloxone into each nostril Injectable: Inject the entire vial into the upper arm or thigh Continue rescue breathing (or CPR, if you re trained) as needed If the person doesn t respond to 1st vial of naloxone, wait 2-5 minutes and give the 2nd vial

48 Success of Naloxone Program Survey of 519 cases of naloxone use: 512 reports of successful use of naloxone Two deaths reported both reportedly involved high levels of benzodiazepines, one was a suspected suicide. Five reports of unknown outcome. 309 reported performing rescue breathing, in addition to naloxone administration (60%). 911 called in 41 cases (8%). Out of 467 cases where 911 was not called, 345 (74%) gave the reason for not calling 911 as fear of police involvement. PPP date updated 6/30/11

49 Facts OD is rarely instantaneous ODs often happen in the presence of others Narcan doesn t make people violent Having Narcan doesn t make people use more or go into treatment less Knowing what to do during an overdose gives drug users and the people who care about them hope

50 Naloxone Pilot Project Type date here

51 Naloxone Pilot Project As much as we want our patients to get it the first time, to leave rehab and abstain from drug use for the rest of their lives, we know, for a significant number of our patients, that isn t realistic. And that is especially so for those with opiate dependence. One of the most dangerous periods for overdose risk is immediately following discharge from a treatment program. Because the person s physical tolerance for heroin or other opiate medications has decreased significantly during treatment, going back and using the same amount of the drug as their last dose can be deadly. Of course we want them NOT to use, but we know that some will. We need to educate our patients and their families about the risks of relapse, including overdose, AND give them the tools to protect themselves and/or reverse overdose.

52 Naloxone Pilot Project Through the Naloxone Pilot Project we propose to: Train GRC staff on ways to address relapse, overdose and prevention Educate patients and families on ways to reduce risk and reverse overdose Distribute intranasal doses of naloxone to patients and/or family members Track patients and families over time to measure: Rates of relapse Use of naloxone Rates of overdose Rates of family anxiety

53 NALTREXONE OPIOID RECEPTOR ANTAGONIST Bullet proof vest against opioids Daily tablet (ReVia) FDA approved Monthly injection (Vivitrol) FDA approved Implants not FDA approved

54 NALTREXONE FOR OPIOID DEPENDENCE Naltrexone Blocks opiate receptors Compliance impacts effectiveness Very effective in certain populations Not addicting, no psychoactive problems

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58 HEROIN TREATMENT There is a broad range of treatment options for heroin addiction, including medications as well as behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop heroin (or other opiate) use and return to more stable and productive lives.

59 Enter buprenorphine Effective treatment option for opioid dependence (Ling et al 1998) Reduces morbidity and mortality (Auriacombe et al 1998) Improves quality of life (Giacomuzzi, et al 2003, Anisse, 2001)

60 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone)

61 Objectives of maintenance treatment To reduce mortality from overdose and infection To reduce opioid and other illicit drug use To reduce transmission of HIV, HBV and HCV To improve the general health and well-being of patients To reduce drug-related crime To improve social functioning and ability to stay in work

62 Treatment saves lives 1996 Subutex and methadone 600 No. of deaths French population in 1999 = 60,000,000 Patients receiving buprenorphine (1998): N= 55,000 Patients receiving methadone (1998): N= 5,360 Year Auriacombe et al., 2001

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65 Goal = Rehabilitation Several objective outcomes to monitor Abstinence from drug use is just the start Treatment is about more than taking medication Aligns management of addiction with other chronic medical problems

66 Individuals with regular involvement in 12-step programs have a 4.5 times higher rate of stable recovery after 5 years Kaiser-Permanente California Study 2004 ASAM Annual Scientific Meeting

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69 U.S. Attorney s Working Group on Drug Overdose and Addiction: Prevention, Intervention, Treatment and Recovery Final Report and Recommendations Pittsburgh, Pennsylvania September 29, 2014

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71 You have to admit your ignorance in order to come to knowledge because nobody is going to search for knowledge if they think they already have it Socrates

72 Addiction is a BIO-PSYCHO-SOCIAL- SPIRITUAL DISEASE Good treatment address all four aspects

73 ADDICTION BATTERS A THRIVING FAMILY

74 NEIL A. CAPRETTO, D.O., F.A.S.A.M. MEDICAL DIRECTOR GATEWAY REHABILITATION CENTER 100 MOFFETT RUN ROAD ALIQUIPPA, PA , x1119

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