1. Medication Assisted Treatment: The History of OPIOID Addiction and Treatment
Jeanne Keen, MS, RN, CADC
DCBS/Family Violence Prevention Branch

2. So we know we have a problem – but what are opioids?
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 1999.
In 2010, about 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers in the past year.
Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription painkillers.
Have been 8 fatal overdoses of heroin documented in Fayette County in 2013.
Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.
According to NIDA – 605,000 abused Heroin in 2009
So we know we have a problem – but what are opioids?

3. History of Opiate Use and Abuse
Meet PAPAVER (Papa Bear) SOMNI’FERUM otherwise known as the Poppy plant!
Archeological remnants of poppy seeds since last Ice Age
5000 B.C. Our first clear records of the poppy plant were provided by the Sumerians (now Afghanistan and Iraq) who called it the Plant of Joy. By 2000 BC The Egyptians were enjoying this powerful drug and by 1300 BC this profitable product has spread across the Mediterranean sea and into Europe.
The Plant of Joy was written about in Homer’s Odyssey in 1000 BC
Alexander the Great took it with him when he invaded India in 340 BC.
Hippocrates was an advocate of using the plant for medicinal purposes.
Opium was brought into China by 400 AD and quickly began to spread across Europe.
It found it’s way to the “New World” in the 1600”s. We’ll talk more about that in a minute

4. Harvest Time
Most of the illicit opioid product comes from family owned and run farms. Harvesting is a long tedious process and begins about two weeks after the petals fall off.

5. Scoring
This is a picture of a poppy pod that is ready to be harvested. It is “scored” by hand using a knife or special tool. It can’t be too deep (won’t be able to get the opium) or too shallow (opium will dry out).
The milky liquid that fills the seed pod is separated and dried and can then be ingested.
One poppy pod may be scored 3 or 4 times. The farmers work backwards as to not disturb the oozing opium.

6. Raw Opium
Turkey, India, UK and Afghanistan are primary producers of legal opium. Afghanistan was producing 70% of the worlds opium until the Taliban placed a ban against opium production and it fell 94%. After the Taliban was removed from power Afghanistan restored its opium production and it is now it is producing 84% of the worlds opium.
Many wars have been fought over this powerful and profitable commodity.
The stuff wars have been waged over, millions of people have lost their lives to addition, and at the same time it has prevented and relieved much pain and suffering.

7. Modern Poppy Harvesting
More than 500 tons of opium or its equivalent in poppy straw concentrate are legally imported into the United States annually for legitimate medical use. We are the largest importer. 90% of narcotic medications are used in this country.
A more modern method of harvesting is by the industrial poppy straw process of extracting alkaloids from the mature dried plant. The extract may be in liquid, solid, or powder form, although most poppy straw concentrate available commercially is a fine brownish powder.

8. Belly up to the bar, boys?
By the mid 1800’s America, Opium dens were popular and scattered through the “wild west”. Wild Bill Hickock and Kit Carson are two of the famous cowboys known to frequent the opium dens.

9. About the same time an English pharmacist, Thomas Sydenham combined opium with wine, producing a compound that became known as Laudanum. This became a popular tonic and was used for various ailments into the 20th Century and gave rise to more opium dependence and it was seen mostly in well to do women. There was no negative stigma attached to the ladies who used the elixir.
Joy to the world!

10. Morphine
In 1804 a German chemist (Friedrich Serturner) extracted the most active component from the poppy and named it Morphine after the Greek god of dreams “Morphheus”. Physicians began to focus on the two powerful effects of the substance: it could bring sleep and it could relieve pain.] The drug was first marketed to the general public in 1817 as an analgesic, and also as a treatment for opium and alcohol addiction. Merck
Morphine is much more powerful that codeine and is the standard by which other narcotics are measured.

11. 1887 Ad for the opiate morphine
Mrs. Winslow's Soothing Syrup was an indispensable aid to mothers and child-care workers. Containing one grain (65 mg) of morphine per fluid ounce, it effectively quieted restless infants and small children. It probably also helped mothers relax after a hard day's work. The company used various media to promote their product, including recipe books, calendars, and trade cards such as the one shown here from 1887 (A calendar is on the reverse side.).
In coka cola
Mrs. Winslow's Soothing Syrup

12. In 1843 Scottish physician, Alexander Wood, developed a new technique for administering morphine – the syringe. This made the effects quicker and more powerful and was immediately put to use on the battlefield.
One of the first wars where morphine was administered to soldiers was the American Civil War. Many surgeries, especially amputations were able to be done to save lives. But left in this wake were 400,000 soldiers addicted to morphine. This was called “The Soldiers Disease”. Ten years after it’s arrival in this county morphine addiction was a major epidemic. Doctors were concerned and began to try to understand how to treat this epidemic.

13. Codeine
In 1832, a French chemist and pharmacist isolated Codeine from the unripe pods of the poppy plant. It isn’t as powerful as morphine. This paved the way for a new generation of safer, codeine-based specific antitussive and antidiarrheal formulations.
The name of the drug, “codeine” dates back to the Greek word kodeia which is the term for “poppy head.
Codeine is currently the most widely used opiate in the world,[22][23] and is one of the most commonly used drugs overall according to numerous reports by organizations including the World Health Organization – we’ll come back to this a little later!

14. Heroin
In 1874 another anesthetic was synthesized by C.R. Wright, working at the German chemical company, FARBEN Corporation, by boiling morphine over a stove. It was manufactured by The Bayer Company in l898. They called it Heroin (Aspirin) and began marketing it as the “cure for the terrible morphine addiction”. (Morphinism) Free samples were given away to morphine addicts. They eventually realized that heroin was even more addictive than morphine and took it off the market in l913.

15. The problem of cough has been solved by using Heroin syrup!
Heroin based cough medicine, introduced in 1898 was almost immediately misused for its euphoric qualities

16. Demo So, from the Poppy Plant – the Plant of Joy comes Opium
From opium comes Morphine, Codeine and Heroin.
These are Natural opioids. But how do they work?? DEMO
Demo

17. By the late 19th century, two-thirds of the people addicted to opioids were middle and upper-class white women. By l900 there were 300,000 opiate addicts in the US. Until the early 20th century US society viewed addiction among women and war veterans sympathetically and treated these groups with tolerance and empathy. Doctors freely prescribed opioids and sanatoriums were established for “cures” of the resulting addictions. They realized that these “cures” didn’t work as people went back to using after leaving the sanitariums. Ten years after it’s arrival in this county morphine addiction was a major epidemic. Attitudes about opiates and addicts began to change. Doctors became more cautious in prescribing opiates, smoking opium was looked at as immoral, and the increase use of needles had a profound effect on opioid use in this country.

18. In 1919, congress passed the Harrison Narcotic Act, essentially banning the sale of opiates. This Act made it illegal for physicians to treat people suffering from addiction to opiates.
The intent of this legislation was laudable but the unintended consequence was that it took the medical profession out of addiction services and left it to the criminal justice system.
Since prescription and over the counter opioids were no longer readily available, illicit Heroin use sky-rocketed and became a large social and legal problem.
Population changes – waves of European immigrants came into big cities, crowded into ghettos and tenement housing which concerned religious, political and social leaders and gave rise to a negative and more punitive approach to addiction.
During the 1930s the US Public Health Service opened three prison/hospitals for addicted persons.

19. The Lexington, KY Narcotic Farm
Site of Narcotic Farm in Lexington , KY. Opened in “New Deal for the Drug Addict”. Established by congress in response to increase in addicts in US prisons and to satisfy those who though arresting addicts was unjust, they would run these prisons as hospitals where addicts could get medical treatment.

20. Hospital or Prison?
Front of building. Note absence of fences Over front door: United States Narcotic Farm. It epitomized the nation’s ambivalence of how to deal with the drug problem. On one hand it was a humane and compassionate hospital. On the other it was an imposing federal prison built for the incarceration of drug accts. Researched drug addiction and did clinical trials on treatment and medications until the early 70’s. Now the Federal Correctional Institute.
For awhile it was a women’s prison – Leona Helmsley
Now a medical facility

21. Meanwhile in Germany…..
During World War II, Germany was cut off from its supply of opium, and therefore had inadequate supplies of morphine to treat battlefield injuries. German chemists found a substitute for morphine with a synthetic compound that was as effective at relieving pain. This compound is now called Methadone.
When Germany collapsed in 1945 the Farben plant was acquired by Eli Lilly, and American pharmaceutical company and began to be used in clinical trials at places like NARCO

22. Dole and Nyswander
Dr. Marie Nyswander worked at NARCO and wrote “The Drug Addict as a Patient.” Dr Dole read the book and recruited her to join his research team at Rockefeller University. They had become convinced that there was more to addiction than environment, poor choices and the seemingly endless revolving doors of the criminal justice and prison systems.
They initiated their research utilizing a little known pain medication, methadone and a dozen or so individuals with long histories of heroin addiction interspersed with reoccurring visits to Rikers Island.
Their hypothesis was that narcotic addiction was capable of being treated much like many other chronic diseases of the day and quickly gave rise to the availability of Federal funding for treatment and infrastructure development which would specialize in the study of narcotic addictions. .

23. Some of the earliest clinical trials on methadone were done at NARCO
And a lot of that research was done in Lexington.
Some of the earliest clinical trials on methadone were done at NARCO
Lots of jazz musicians came to Lexington for the “cure” and gave free concerts on Sunday afternoons and appeared once on the Johnny Carson show.
Treatment included recreation, work, spirituality, talk therapy, and drug research. It became the epi-center for drug treatment and addiction research.

24. Dole/Nyswander Hypothesis:
Heroin (opiate) addiction is a disease – a “metabolic disease” of the brain with resultant behaviors of “drug hunger” and drug self- administration, despite negative consequences to self and others. Heroin addiction is not simply a criminal behavior or due alone to antisocial personality or some other personality disorder. 1963
As the addict volunteers had been built up to large doses of narcotics by street standards, they were given relatively large doses of methadone to stabilize their "habits" before beginning the reduction.
And then something completely unexpected happened. A few days after the subjects had been switched to methadone, and before the "detox" had begun, they began to exhibit very different behavior. Whereas for weeks they had spent their days either feeling the effects of the narcotics or complaining of their need for more narcotics, suddenly the focus of their days turned away from drugs. One subject asked the researchers for supplies so that he might resume his long neglected hobby of painting. Another inquired after the possibility of continuing his interrupted education. In short, the addicts- who when admitted to the hospital had looked and behaved very much alike -now began to differentiate. They began to manifest the potential that each had obscured during years of chasing street narcotics.
The AMA announced that addiction is a disease in 1957
Now let’s talk about “Addiction” What is it??

26. Addiction – “ A brain disease, not a social dysfunction”
Addiction – “ A brain disease, not a social dysfunction”. Green light, Red light responses.

27. Addiction is a brain disease
Chronic
Relapse may occur
Progressive
Causes compulsive drug seeking
Causes use despite harmful consequences
Changes the structure and function of the brain
Can be fatal is left untreated.
Now you don’t have to believe me. In 1957 the AMA declared that Addiction is a disease.
Addiction is a brain disease.
Drugs change how the brain works.
These brain changes can last for a long time.
They can cause problems like mood swings, memory loss, even trouble thinking and making decisions.
Addiction is a disease, just as diabetes and cancer are diseases. Addiction is not simply a weakness. People from all backgrounds, rich or poor, can get an addiction. Addiction can happen at any age, but it usually starts when a person is young.
Addiction is a brain disease, not a weak will. The disease of addiction causes changes in brain chemistry. These brain changes directly affect thinking, judgment, planning, sequencing, memory... So what about choice??

28. Choice? Initial decision to drink or use is voluntary
Over time, changes in the brain caused by repeated use can impact
self-control
ability to make sound decisions
PLUS, causes intense cravings
People who abuse drugs can stop more easily, but they may not think they have a problem!
People with addiction can desire to stop, but it is hard work, and, just like in other diseases, some are not successful
The brain is hi-jacked – Choice is no longer a choice!
And once you really understand this

29. “They just need to stop partying and fly right”
becomes
“They have the disease of addiction. How can we reach them through this disease and support them to overcome it??”
So what if we were to think of “addiction” like we do any other “illness”. Would we say because a person has multiple sclerosis and has difficulty caring for her children that “this means she doesn’t love her children?”, of course not! And this is also true of women who have an addiction.
So what we’re asking you to do is to look at addiction differently. It’s not a sin, a weakness, or a moral problem. It’s a brain disease that can be treated.

30. Take a look at this picture – does everyone see the Toad?
Anyone see the horse?

31. When you change the way you look at things, the things you look at change….
What if we change the way we look at things ---
See it now?
Now let’s talk a minute about addiction treatment…..

32. Treating Addiction Detoxification
Counseling – inpatient and outpatient
Individual
Family
Group
Self-Help
Pharmacological
AA and other self help
AMA – 1957
Pharmacological treatment for addiction is not new –
Nicotine – welbutrin, nicorette, Chantix
Alcohol – antabuse, Camprol, Gabapentin
Cocaine - Neltrexone
We use medications for fighting many diseases – from strep throat to cancer. Why should we be surprised, suspicious or disapproving of using medicines for the treatment of the disease of addiction?

33. Goals for Medication to Treat Addiction:
Prevent withdrawal symptoms
Reduce drug craving
Normalize any physiological functions disrupted by drug use
Remember where we were in our history of opiates? They were doing experiments with Methadone at NARCO in Lexington in the early sixties. And found that it worked! It worked so well that….

34. And in1972…
Methadone Maintenance is approved by the US FDA for treatment of heroin addiction because an efficient oral dose of methadone given once daily to a heroin addicted person effectively prevents opiate withdrawal and associated cognitive and behavioral problems
In 1971 it was discovered that 40% of American troops in Viet Nam had tried heroin and half had become addicted. President Nixon sent one of his first “drug czars” Dr. Sam Jaffe to evaluate the problem and to suggest a solution. Dr. Jaffe learned that there was a new test that could detect heroin in urine which made it possible to screen a large number of people. This was called Operation Golden Flow. He urged that soldiers be screened and those using heroin be immediately placed on methadone treatment. The War against Drugs was on!

35. Demonstrate how methadone works on the receptors Today the methadone maintenance program has been expanded and is the major public health program for the treatment of opiate addition in the United States. From 1964 through 1994 there have been over approximately 2,000,000 patient-years on methadone maintenance treatment in the United States. Presently, there are about 200,000 persons known to be enrolled in approximately 850 methadone maintenance treatment programs in 40 states. Also, methadone maintenance programs are expanding throughout the world to prevent the transmission of HIV. Research shows that when treating
substance-use disorders, a combination of
medication and behavioral therapies is
most successful.
Substance Abuse and Mental Health Services Administration (SAMHSA)
Of the treatment options examined, opioid
agonist maintenance treatment, combined
with psychosocial assistance, was found to
be the most effective.
World Health Organization (WHO)

36. The Opiate Boom!
In America during the l990s, prescription use of pain killers, anti-anxiety medication, sleeping medications and antidepressants increased many times over. Some people believe this is in direct response to pharmaceutical advertisements on TV. Patients began asking their physicians for certain medications they had seen on commercials guaranteed to make them feel better, sleep more, eat less, be calm, be happier and have more sex. The US uses about 90 percent of the prescription medication in the world.
Vicodin (hydrocodone) marketed in 1984
Oxycontin 1995
Percocet (reformulated with oxycodone)
by million prescriptions were written in the US

37. Prescription Drug Abuse
Abuse of synthetic opiates causes more deaths than heroin and cocaine combined.
In 1991 there were 40 million prescription world wide and by the number rose to 180 million.
Emergency Room visits rose 153 percent from 1995 to 2012.
About 1 in 5 teens has used opiates to get high.
2,500 teens abuses prescription drugs for the first time each day.
Deaths from opiate use increased by 160% from 1999 to
Experts predict that abuse of prescription drugs will increase by 190 percent by 2020.
Young adults show the most increase in opiate abuse.
Misconceptions about their safety – Because they’re prescribed by doctors many assume they’re safe to take. Prescription drugs act on the same brain systems affected by illicit drugs and can lead to addiction just like illicit drugs.
Increasing environmental availability – Between l991 and 2010 prescriptions for stimulants increased from 5 million to 45 million, a 9-fold increase, and opioid analgesics increased from about 30 mil to 180 mil, a 6-fold increase.

38. Oxycodone
Oxymorphone
Hydrocodone
Vicodin (hydrocodone) marketed in 1984
Oxycontin 1995
Percocet (reformulated with oxycodone)
Oxycodone – percocet, oxycontin, Endocet, Tylox, roxicodone
Hydrocodone – Vicodin, Lortab
Oxymorphone – Opana, Numorphan

39. Subutex/Suboxone (2000)
One of the newer synthetic opiate medications came on the market in It was developed for the treatment of opiate
Suboxone has buprenorphine (opiate pain medication) and naloxone (Narcan) which blocks the effects of opiates. Narcan is used to treat overdose. It is added to suboxone to keep patients from injecting. It is not used in pregnancy.
Both drugs come in 2mg and 8mg strengths
It has been shown to be effective for opiate addiction treatment in patients with shorter histories of opiate use. Studies have shown a better compliance rate with patients prescribed methadone.

40. Here is what you need to understand: Physicians can prescribe suboxone/subutex after taking one 8 hour seminar on the drug. Some are addictionologists, psychiatrists, and/or have experience in treating drug addiction. Some don’t. There are now 57 physicians prescribing Buprenorphine in Lexington. IF you have a client taking subutex or suboxone you have to know who is prescribing. Is there any treatment that goes along with the medication? Individual therapy? Group therapy? Referral to community services? Is there any monitoring? Are there routine drug screens? How is compliance measured? There are good buprenorphine clinics and you have to be aware of who is prescribing the drug for your client.

41. Kentucky Counties in Crisis
By 2010s Ky was in a crisis
876 Overdose deaths in 2013 (Bell, Clinton, Breathitt, Floyd, Perry and Harlan)
3rd in Nation

42. KY Legislators respond to Crisis in 2012 - House Bill 4
KASPER Reports
Increased Regulations for Pain Clinics
House Bill 4 – PILL MILL BILL All prescribers must register with the Kentucky All Schedule Prescription Reporting (KASPER) and run a KASPER report on individual patients before writing prescriptions for scheduled drugs. If prescribing meds for three months or longer the physician must do random UDS to assure patient isn’t using other drugs.
All pain clinics have to be owned by someone licensed by a professional licensing board and must follow KASPER guidelines.
Closed 36 clinics, saw 8.5% drop in prescriptions.

43. And Now the HEROIN BOOM! National Drug Intelligence Center
Supply and Demand and Money! Opana going for $ a pill Heroin selling for about $15 for one-tenth of a gram (one dose)

44. The Boom continues…..
There have been over 1600 heroin trafficking charges issued in Louisville.
In 2015, there were 1,248 over dose deaths from heroin use.
A person dies every 36 minutes in the U.S. from a heroin overdose.
A special task forces have been created to look at the heroin problem statewide and locally. TOP five counties – Jefferson, Fayette, Kenton, Boone and Campbell

45. Legislators Respond in 2013
PAR . SB 38 would make it legal for a doctor to prescribe and a person to carry Naloxone (Narcan) for the purpose of administering it in a case of opiate overdose. These people would be exempt from civil and criminal liability for administering the drug in good faith. In San Francisco, this measure reduced opiate overdose deaths from 150 to 10 per year.

46. Naloxone (Narcan)
You can either give it as an injection or a nose spray

47. NARCAN Use in Louisville
Narcan was used 832 times by the Louisville EMS from the beginning of until the end of May.

48. Legislators Respond in 2014
Medicaid Expansion – will now cover substance use disorder treatment
Great news for people suffering from addiction who previously could not afford to get the help they need.
Education, access to substance abuse treatment, greater penalties for major traffickers, and greater access to the Naloxone (Narcan) are key components of battling addiction and was introduced before the 2014 Kentucky General Assembly in Senate Bill 5. It died on the floor but may come back in a special session

49. Legislators Respond in 2015
The Heroin Bill
Greater penalties for major dealers
Narcan more readily available
Limitations on prescribing Buprenorphine
Education and Prevention
$10 Million for Treatment
Great news for people suffering from addiction who previously could not afford to get the help they need.
Education, access to substance abuse treatment, greater penalties for major traffickers, and greater access to the Naloxone (Narcan) are key components of battling addiction and was introduced before the 2014 Kentucky General Assembly in Senate Bill 5. It died on the floor but may come back in a special session

50. METHADONE TREATMENT
Medication is only one component ( wrap around services)
Detoxification v. Maintenance (MMT)
Opiate Treatment Programs
Overview of average OTP
Federal and State regulations
Kentucky’s programs

51. Kentucky Opioid Treatment Programs

52. METHADONE BENEFITS
Right dose does not cause euphoric or tranquilizing effects
Reduces/blocks effects of other opiates.
Tolerance is slow to develop.
Relieves cravings.
Decrease in criminal activities.
Allows the individual to feel “normal”
Over forty years of research.

53. METHADONE BENEFITS Improved employment status
Decrease in high risk behaviors such as IV drug use which decreases risk of HIV and Hepatitis C.
Improved health and health care.
Improved employment status
Improved family relationships and ability to parent.

54. METHADONE LIMITATIONS
Increased risk when combined with other drugs. (Benzodiazapines)
Can only be dispensed/administered through a licensed Opiate Treatment Program (OTP)
Private programs can be expensive.
Heavily regulated, lots of rules, can be time consuming.
Diversion of medication

55. BUPRENORPHINE Partial mu opioid agonist (ceiling effect)
Long half-life (24-60 hours)
Administered as sublingual film
Two types: Suboxone and Subutex

56. SUBOXONE Naloxone added as means to decrease diversion.
Poor bioavailability sublingually, but if dissolved and injected, will precipitate withdrawal.

57. Subutex Contains Buprenorphine only.
Used primarily with pregnant women.
Higher rate of diversion, can be used IV.
Little federal and state oversight.

58. BUPRENORPHINE BENEFITS
Virtually no euphoric or tranquilizing effects.
Blocks effects of other opiates.
Relieves cravings to use other opiates.
Allows “normal” function.
Increased anonymity and less intrusive, vs. attending a MAT clinic daily.

59. BUPRENORPHINE BENEFITS
Increased treatment options/access to treatment.
Decrease in high-risk behaviors.
Good “step down” option for those tapering from Methadone.
Medicaid will pay for medication.

60. BUPRENORPHINE LIMITATIONS
Expensive.
Cannot take if opiates still in your system.
Counseling may not be available or affordable in the same area as doctor.
Doctors limited to 30 patients the first year with a maximum of 100.
Easy to obtain
High diversion rates.

61. BUPRENORPHINE LIMITATIONS
Kentucky Board of Medical Licensure regulation 201 KAR 9:270 ( effective 7/1/2015)
Cannot charge Medicaid clients above reimbursement rates
Drug testing and counseling guidelines
Abuse and diversion potential still exists.

62. NALTREXONE Is not an opiate Blocks opiates
First used primarily to treat alcohol dependence and now used for opioid dependence.
Oral- ReVia – relies on patient compliance
Injectable- Vivitrol injection can be received monthly
Implant- FDA approved as of yet.

63. NALTREXONE TREATMENT Medication is only one component.
Average length of treatment is 3 months but can be used longer.
Works with highly motivated patients.

64. NALTREXONE BENEFITS Any physician can prescribe in any setting.
Non-addictive, does not produce dependence, and does not build tolerance.
More acceptance in abstinence-based programs.
Less stigma than Methadone or Buprenorphine.
KY Medicaid covers, oral is 1st-tier; injectable is a 3rd-tier.

65. NALTREXONE LIMITATIONS
Does not reduce cravings.
Poor compliance with oral version.
No opioids on board for up to two weeks
Injection site reactions can be severe
Risk of overdose
Increases sensitivity to opioids and alcohol.
Cannot be used with pregnant clients.
Risk of liver disease

66. KORTOS – Ky Opiate Replacement Treatment Outcome Study – FY 2014
Abstinence rates increased dramatically ( 6 month review)
Rx opioid use decreased 92% from admission
Non-Rx methadone decreased 82%
Heroin use decreased 96%
Alcohol intoxication down 67%
Arrests down 63%
Decrease in economic hardships down 34%
Improved recovery supports up 138%

67. KEY POINTS TO REMEMBER
No “perfect” medication that is one size fits all.
All 3 medications work significantly better when utilized in combination with counseling, drug screens, etc.
MAT is appropriate for pregnant women and should be closely monitored.
Individuals receiving MAT are in recovery!