1. The Prescription Opioid & Heroin Crisis: Addiction & Medication Assisted Treatment Andrew Kolodny, M.D. Chief Medical Officer, Phoenix House Foundation Inc. Executive Director, Physicians for Responsible Opioid Prescribing Senior Scientist, Heller School for Social Policy and Management, Brandeis University Twitter: @andrewkolodny

2. Conflict of Interests 2 I have no relevant financial relationships to disclose.

3. 3 Incidence of non-medical use of pain relievers has been declining since 2002 Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu Rev Public Health. 2015: 36:559-574

4. 4 2002 2014 Estimated Age-adjusted Death Rates for Drug Poisoning by County SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016

5. 5Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu Rev Public Health. 2015: 36:559-574 Non-medical Rx opioid use vs. opioid Rx OD deaths by age group

6. Three Opioid-Addicted Cohorts 1.20-40 y/o, disproportionately white, significant heroin use, opioid addiction began with Rx use 2.40 y/o & up, disproportionately white, mostly Rx opioids, opioid addiction began with Rx use 3.50 y/o & up, disproportionately non-white, mostly heroin users, opioid addiction began with heroin use 6

7. Heroin treatment admissions : 2003-2013 SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

8. 8 Mortality by cause, white non-Hispanics ages 45–54 Source: Anne Case, Angus Deaton. Rising morbidity and mortality in midlife among white non- Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences. November 2, 2015 (online ahead of print).

9. 9 Rate of hospital inpatient stays related to “opioid overuse”, 1993 and 2012 Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS), 1993 and 2012

10. Heroin admissions, by gender, age, and race/ethnicity: 2013 SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

11. Opioid Related Overdose Deaths United States, 1999-2014

12. Buprenorphine Experience in France Introduced in the mid 90s 79% decline in OD deaths in 6 years Use of mono product (not formulated with naloxone) associated with diversion and injection use Source: Auriacombe et al. French field experience with buprenorphine. Am J Addict. 2004

13. Heroin treatment admissions with planned medication-assisted opioid therapy 2003-2013 SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

14. Barriers to Buprenorphine Ideological Federally imposed patient caps Federally imposed ban on NP and PA prescribing Limited integration of addiction treatment in primary care Prior authorization requirements

15. Questions?