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Responding to the Opioid Addiction Epidemic Andrew Kolodny, M.D. Chief Medical Officer Phoenix House Foundation New York, NY.

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Presentation on theme: "Responding to the Opioid Addiction Epidemic Andrew Kolodny, M.D. Chief Medical Officer Phoenix House Foundation New York, NY."— Presentation transcript:

1 Responding to the Opioid Addiction Epidemic Andrew Kolodny, M.D. Chief Medical Officer Phoenix House Foundation New York, NY

2 The Opium Poppy Papaver Somniferum 2

3 Crude Opium Latex on Poppy Head 3

4 Opioids Morphine Codeine Thebaine Diacetylmorphine (Heroin) Hydrocodone (Vicodin) Oxycodone (Oxycontin) Oxymorphone (Opana) Hydromorphone (Dilaudid) Naturally occurring opioids- also called opiates Semi-synthetic opioids

5 Prior Opioid Addiction 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 Male > Female

6 6 Governor Shumlin devotes entire state of the state speech to Vermont’s opioid addiction epidemic

7 Heroin Cocaine 38,329 drug overdose deaths in 2010 Unintentional Drug Overdose Deaths United States, 1970–2007 National Vital Statistics System, Year

8 Drug Overdose Deaths by Major Drug Type, United States, 1999–2010 CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

9 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 9

10 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 10

11 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 11

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

13 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 13

14 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 14

15 15 Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011

16 16 Heroin admissions, by age group & race/ethnicity:

17 Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary. Number of Deaths Opioid sales (mg/person) *

18 Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010 CDC. MMWR 2011

19 19

20 20

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

22 Industry-funded “education” 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. 22

23 Industry-funded organizations campaigned for greater use of opioids Pain Patient Groups Professional Societies The Joint Commission The Federation of State Medical Boards 23

24 Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med Jan 10;302(2):123 Cited 824 times (Google Scholar) “The risk of addiction is much less than 1%” 24

25 N Engl J Med Jan 10;302(2):

26

27 “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”.

28 The Emperor’s New Paradigm: Patient Selection, Risk Stratification & Monitoring 28

29 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):185–

30 Controlling the epidemic: A Three-pronged Approach Prevent new cases of opioid addiction. Treatment for people who are already addicted Supply control- Medical board & law enforcement efforts to reduce over- prescribing and black-market availability. 30

31 Opioid manufacturers continue to advertise opioids as safe and effective for chronic pain.

32 How the opioid industry Frames the Problem Source: Slide presented by Lynn R. Webster MD at FDA meeting on hydrocodone upscheduling, January 25 th, 2013.

33 33 Drug overdose death rates by intent by age group, US, 2008

34 Pain Patients “Drug Abusers” 63% admitted to using opioids for purposes other than pain 1 35% met DSM V criteria for addiction 2 1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8: Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30: This is a false dichotomy Aberrant drug use behaviors are common in pain patients 92% of opioid OD decedents were prescribed opioids for chronic pain. 3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, J Gen Intern Med Oct 16.

35 Frequently Discussed Interventions Abuse-deterrent formulations Expanding access to naloxone Expanding access to medication assisted treatment PDMP-based interventions Mandatory prescriber education 35

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37 Buprenorphine Treatment Partial agonist –Weaker effects –Safer to use Long duration of action Milder withdrawal symptoms

38 Full Opioid Agonists

39 Buprenorphine- A Partial Agonist

40 Summary We are in the midst of the worst drug epidemic in U.S. history. To end the epidemic we need to: –PREVENT new cases of opioid addiction –TREAT people who are already addicted 40

41 Please visit


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