1. ADDICTED NATION Brent Boyett D.M.D.,D.O.

2. Disclosure Paid Speaker for BDSI Pharmaceuticals. Paid Speaker for Choice Laboratories. Paid Speaker for PCLS Laboratories. Paid Speaker for Orexo Pharmaceuticals. Paid Advisory Panel for BDSI Pharmaceuticals.

3. Clinical Research Primary Investigator Braeburn Pharmaceuticals BDSI Pharmaceuticals Orexo Pharmaceuticals Indivior Pharmaceuticals Novo Nordis Pharmaceuticals Pfizer Pharmaceuticals.

5. Land of Excess

9. Broken Down By Age

10. Appalachian “Pillbillies”

11. Alabama is Number 1

12. PREGNANCY IN ALABAMA The rate of NAS in Alabama is nearly 3 times the national average. Alabama - 16.2 /1000 Births National average – 5.8/1000 Births

13. PREGNANCY IN ALABAMA Alabama Medicaid cases of NAS have doubled in 3 years and they continue to climb. 170 in 2010 345 in 2013

14. PREGNANCY IN ALABAMA NAS cost Alabama Medicaid $23.3 million between 2010 and 2013.

15. PREGNANCY IN ALABAMA 67% of NAS in Medicaid claims are deliveries from mothers withOUT an opioid prescription. Diversion – Selling, sharing and trading.

16. Chronic Pain Has Become The Politically Correct Term for Addiction

17. Taking Action

18. “Operation Pilluted” arrested 22 Doctors and Pharmacist in 4 states earlier this year

19. Two Approaches to Drug Abuse Supply Reduction: Criminalization Regulation Incarceration Border control

20. Two Approaches to Drug Abuse Demand Reduction Treatment: Abstinence (Sober living) MAT Education Early Intervention SBIRT

21. Shift in Public Opinion

22. Plan to Double the Number of Doctors Providing MAT Within the next 3 years

23. How We Will Pay

24. Obama Plan $922 million will be used for form cooperatives with states to provide MAT. Funding will be awarded based on need and strategy.

25. CDC ESTIMATES A savings of $150 billion / year in healthcare dollars if we just treat addiction as a chronic disease.

26. Prescribing Controlled Substances in the 21 st Century There are many new considerations. Informed consents Written Policy Diversion mitigation Drug testing Documentation

27. May 13,2015, a 3 to 2 decision in the West Virginia Supreme Court ruled that doctors and pharmacist can be sued for medical malpractice for there role in pain medication abuse, even if the patient is dishonest with the doctor.

28. Dr. Lisa Tseng, Guilty of Murder

29. Accessing Risk for Abuse Family History of Chemical Dependence (Including tobacco, benzodiazepines and alcohol). Social History of Substance use ( Including tobacco, “benzos” and alcohol). Medical History of Depression or Chronic anxiety disorders (Chronic emotional pain)

30. Statistic show If a patient takes an opioid pain medication daily for 30 days, There is a 47% chance they will still be taking them in 3 years.

31. Mechanism of Dependence and Tolerance Dopamine receptor down regulation in the Periaqueductal gray matter and the Rostroventral Medulla. Loss of Glutamate inhibition of prefrontal cortex on the nucleus accumbens. Hyperalgesia Loss of Descending anti-nociceptive (pain) pathways

32. Pain and Behavior

33. Percentage of Patients Referred to Quest Diagnostics Laboratories for Drug Testing by Their Physicians Testing Positive and Negative for Drugs Prescribed for Them, 2012

34. How did we get to here? Quality measures Pain scores – Pain, the fifth vital sign. Patient satisfaction surveys.

35. How did we get here? Pain pills and nerve pills are good business. Patients are happy (in the short term) The government is happy. (Patient satisfaction scores, low pain scores.) Full waiting rooms make doctors happy.

36. Healthcare Success Stories Success in Healthcare is not always about “the cure”. Prevention Early detection Chronic management (Harm reduction)

37. Historic Approach to SUD Treatment Treated as an acute illness. “Fix em and forget em”. “Good luck” “Join a 12 step program” “Don’t relapse” Like correcting DKA and discharging with only diet and exercise.

38. Future Approach Prevention Early detection – “Problem users” Chronic – long term management. Majority will be managed as an outpatient (ambulatory) setting.

39. WHO WILL NEED CARE?? 1. Currently 2.3 million Americans in Treatment for Addiction (Chemical dependence). 2. Estimated 25 million Americans suffer from Addiction (chemical dependence) and are NOT in care. 3. Estimated 60 million harmful user in the U.S.

40. WHO WILL NEED CARE?? 4. 60 million harmful users + 25 million chemically dependent = 85 million patients in the U.S., in need of care. 5. Why target Harmful Users? Remember, early detection and early intervention are a key strategy.

41. SUD, should be treated according to other chronic disease models To ignore the harmful user population would be like not; Addressing hypertension until after the stroke. Looking at cholesterol after the heart attack. Addressing diabetes after the amputation.

42. IT’S NOT ALWAYS ABOUT THE CURE Chronic disease management reduces the risk for bad outcomes. Bad outcomes for diabetes MI Stroke Amputation Vision loss

43. IT’S NOT ALWAYS ABOUT THE CURE Chronic disease management reduces the risk for bad outcomes. Bad outcomes for diabetes MI Stroke Amputation Vision loss

44. IT’S NOT ALWAYS ABOUT THE CURE Chronic disease management reduces risk for bad outcomes. Bad outcomes for addiction Financial collapse Criminality Damaged relationships Multiple health problems

45. Medical Assisted Treatment It is long term approach to the management of a chronic disease. Very much like other chronic diseases. Diabetes Hypertension

46. Medical Assisted Treatment Insulin= methadone or buprenorphine (Suboxone, Bunavail or Zubsolv). Harm reduction in diabetes reduces the risk of: Amputations Nephropathy MI Stroke Retinopathy

47. HARM REDUCTION Harm reduction in addiction reduced the prevalence of : Damaged relationships Lost function Criminality Financial loss Collapse of family structure Lost productivity

48. BUPRENORPHINE A partial agonist (limited intrinsic activity) High affinity (slow dissociation) Competes with other opiates for the mu receptors and will displace full agonist resulting in an induced withdrawal. Long half life allows for infrequent dosing.

49. BUPRENORPHINE A weak mu agonist Slight reward aids in compliance Has a ceiling effect Prevents abuse from binge dosing. Prevents further dopamine receptor pruning as a result of falsely elevating the hedonic tone.

50. BUPRENORPHINE Strong affinity tends to displace any full agonist. This blocks the full agonist affect or causes withdrawal if the patient takes the two together.

51. Buprenorphine: A Partial Mu Receptor Agonist TIP 43 Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs SAMHSA Dose of Opioid Opioid Effect Full Agonist (e.g. Methadone) (e.g. Naloxone) Antagonist Partial Agonist (e.g. Buprenorphine) Ceiling effect

52. Buprenorphine plus naloxone Naloxone – full mu antagonist which is only effective when injected Injected naloxone result in a rapid displacement of the full agonist resulting in displacement and mu receptor blocking. In the sublingual route, the bioavailability is so low the naloxone has no effect. SUBOXONE, BUNAVAIL or ZUBSOLV

53. It is not “a one size fits all” approach Custom dosing based on tolerance and dependence. Some patients may be able to taper to abstinence and others may not. Patient should be titrated to the lowest effective dose that controls symptoms and craving. Medical Assisted Treatment

54. Analytical Mind vs. Reactive Mind

55. Two beings in one.

56. History Repeats Itself

57. The Osteopathic way