1. Lisbon Addictions 2017 The Evolution of the Opioid Abuse Epidemic in North America October 24, 2017
Richard C. Dart, MD, PhD
Executive Director, RADARS System
Professor, University of Colorado School of Medicine

2. RADARS® System Conflict of Interest Statement
Most manufacturers of prescription opioids or stimulants subscribe to RADARS System.
RADARS System is the property of Denver Health and Hospital Authority, a political subdivision of the State of Colorado.
Subscribers receive information, but do not participate in development, data collection, or analysis of the data. They do not have access to the raw data.
Employees are prohibited from personal financial relationships with any company.
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3. Supply of Legal Opioid Analgesics
The supply of legal highly addictive drug has increased in many countries.
(I will go over details briefly)
2 minutes

4. What is the Problem We Need to Solve?
Filling the Balloon
Chewed
Crushed
Intact
Person in Pain
Death
Outcomes
Addiction
Overdose
Susceptible
Person
Recreational Abuser
Abuse of Other Drugs

5. Rudd et al. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82.

6. Opioid Overdose Mortality in US is Primarily White, Non-Hispanic
> 80%
White, Non-Hispanic
Black, Non-Hispanic
Hispanic
CDC Wonder, analyzed by Kaiser Family Foundation:

7. Mosaic Surveillance of Prescription Drug Abuse
Acute Health Events
Poison Center Program
Non-Medical
Use
Survey of Non-Medical Use of Prescription Drugs (NMURx)
Entering Treatment
Survey of Key Informants’ Patients
Drug Transactions
Drug Diversion Program
Entering Treatment
Opioid Treatment Program
StreetRx.com
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EXPLAIN:
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Advanced Users/Targeted Investigations
Researcher & Patients Interacting Directly (RAPID)
Illicit Market Price
StreetRx Program
Internet
Chatter
Web Monitoring Program

8. Prescription Opioid Abuse is Declining in the US
Poison Centers
Drug Diversion
Substance Abuse Treatment Centers
Dart RC, et al. Trends in Opioid Analgesic Abuse and Mortality in the United States. N Engl J Med 2015;372:241-8

9. Hydrocodone & Oxycodone Dominate Rx Opioid Abuse in US
RADARS Poison Center Program
Intentional Abuse Exposures
CDC
Per
100,000
population

10. Evolution of Prescription Drug Abuse in US
WA Rx Guidelines
Oxycodone ER
Reformulation FL
TIRF REMS
ER/LA REMS
HC-APAP Tramadol
National Drug Take Back
CDC Pain Guideline
Oxycodone ER
PDMP
Other Opioids
Other Opioids

11. Potential Effects of Interventions
Emptying the Balloon
Chewed
Crushed
Intact
Person in Pain
ADF
ADF
Dth
Outcomes
OUD OD
Guidelines
PDMP
Enforcement
Susceptible Person
Recreational Abuser
Heroin
Treat
Abuse of Other Drugs

12. Percentage Drug Deaths Comparing 2010, 2014, 2015
Hedegaard H, et al. Drug overdose deaths in the United States, 1999–2015. NCHS data brief, 273. National Center for Health Statistics

13. Most Opioids
Rudd et al. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):

14. Divergence of Heroin and Rx Opioids - 2008
N Engl J Med 2015;372:241-8

15. Heroin and Other Drugs Push? Or Pull?
Alcohol
Marijuana
Opioid Abuser
Availability
Cost
Setting
Heroin
Rx Opioid
I honestly don’t think so. Here is my reasoning. The vast majority of peoply who end up using heroin have a long track record.
They typically started with alcohol, then abused marijuana and, often, other drugs as well. At some point they are make a conscious decision on whether to try an opioid. They make this decision similar to consumers of other products – availability, cost and in the case of drug abuse – setting.
Thus, the so-called push to heroin is actually a pull. Heroin is just the most available and cheapest form of opioid available today.
Benzodiazepines
Gabapentanoids
Antipsychotics

16. Ever-Expanding List of Drugs of Abuse
Opioids (heroin, prescription analgesics, loperamide)
Stimulants (methamphetamine, cocaine, Adderall, Concerta, synthetic cannabinoids)
Cannabinoids (marijuana)
Hallucinogens (LSD, peyote, ketamine)
Antipsychotics (olanzapine)
Novel psychoactive substances (NPS) “Designer Drugs”
Any CNS active drug?
Gabapentin, pregabalin
Nicotine

17. Summary
Prescription opioid abuse peaked and has subsequently decreased steadily
Illicit opioid abuse transformed by new distribution methods and is increasing rapidly
Deaths occur primarily due to fentanyl-laced heroin
Substance abuse is complex
Focusing on one or two agents may produce misleading