Responding to the Opioid Addiction Epidemic 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 Research Professor, Global Institute of Public Health, New York University

2 Opium

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

Heroin Cocaine 43,982 drug overdose deaths in 2013 Unintentional Drug Overdose Deaths United States, 1970–2007 National Vital Statistics System, Year

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.

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.

Opioid Overdose Deaths United States,

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

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

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

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

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

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

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

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

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) *

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

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Industry-funded “education” on opioid use for chronic non-cancer pain: Doctors are needlessly allowing patients to suffer because of “opiophobia” Risk of addiction is “very low” Physical dependence is “clinically unimportant” Safe and effective for chronic pain 20

Controlling the epidemic: A Three-pronged Approach Prevent new cases of opioid addiction. Treat people with disease of opioid addiction. Control supply from pill mills and black- market availability. 21

Buprenorphine Experience in France Introduced in the mid 90s 80% decline in OD deaths in 6 years Associated with diversion and injection use Source: Emmanuelli J, Desenclos JC. Harm reduction interventions, behaviours and associated health outcomes in France, 1996–2003. Addiction 2005;100:1690–1700.

How Full Agonists Work

Buprenorphine is a Partial Agonist

Oxycodone for Chronic Pain Vs. Buprenorphine for Addiction Oxycodone for Chronic Pain Buprenorphine for Addiction Evidence-Based TreatmentNoYes Controlled Drug ScheduleCIICIII Overdose RiskHighLow Training RequirementNone8 Hour Course Number of patientsUnlimited30/100 NPs/PAs allowed to RxYesNo

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

Retention in Treatment Kakko, Lancet 2003 Treatment duration (days) Remaining in treatment (nr) Detoxification Maintenance

Buprenorphine RCT A Tragic Appendix: Mortality Kakko, Lancet 2003 PlaceboBPN Dead4/20 (20%)0/20 (0%)

Summary The U.S. is in the midst of a severe epidemic of opioid addiction To bring the epidemic to an end: – We must prevent new cases of opioid addiction –We must ensure access to treatment for people already addicted