Opioid Use Disorders: Recognition and Pharmacotherapy Review Joji Suzuki, MD Director, Division of Addiction Psychiatry Department of Psychiatry, Brigham and Women’s Hospital Assistant Professor of Psychiatry, Harvard Medical School

Epidemiology Update: How Did We Get Here?

Overview Overview of current state Deaths caused by drug-related overdoses vs traffic accidents How we got here: three key developments Started in the early 90’s and have a direct impact in the present Non-medical or recreational use Most common opioid sources What happens after recreational use begins?

Overview Overview of current state Deaths caused by drug-related overdoses vs traffic accidents How we got here: three key developments Started in the early 90’s and have a direct impact in the present Non-medical or recreational use Most common opioid sources What happens after recreational use begins?

Overview Overview of current state Deaths caused by drug-related overdoses vs traffic accidents How we got here: three key developments Started in the early 90’s and have a direct impact in the present Non-medical or recreational use Most common opioid sources What happens after recreational use begins?

Drug-related overdoses

Drug-related overdoses 2014: 28,000 deaths in the US Drug-related overdoses

Drug-related overdoses 2014: 28,000 deaths in the US 70 deaths everyday Drug-related overdoses

Drug-related overdoses Traffic accidents 2014: 28,00 deaths in the US 70 deaths everyday Drug-related overdoses

Drug overdoses: leading cause of accidental death Motor vehicle accidents Drug overdoses: leading cause of accidental death Drug induced overdose

More deaths from prescription opioids than heroin

Overdose deaths/100,000 Opioid sales/10,000

How did we get here?

“Improve pain management” Elderly, HIV patients, cancer 1980 1990 2000

1990 “Improve pain management” Elderly, HIV patients, cancer “Opioids? Be careful” 1980 1990 2000

1990 “Improve pain management” Elderly, HIV patients, cancer “Opioids? Be careful” Changes 1980 1990 2000

Pain assessment “Fifth vital sign”

Greater opioid utilization Pain assessment Greater opioid utilization “Fifth vital sign”

Pain assessment “Fifth vital sign” Greater opioid utilization “Fifth vital sign” Insufficient training in multimodal treatment

Unethical Marketing Unethical Marketing “Non-addictive version of short-acting oxycodone” Oxycontin (Oxycodone CR) (1996)

Unethical Marketing Unethical Marketing No evidence to support claim “Non-addictive version of short-acting oxycodone” No evidence to support claim Oxycontin (Oxycodone CR) (1996)

Non-medical use Unused opioids

Non-medical (recreational) use: Opioids used for purposes other than they were prescribed Self-medicate negative moods Self-medicate insomnia Enjoy euphoria Diversion Snorting

Non-medical (recreational) use: Opioids used for purposes other than they were prescribed Self-medicate negative moods Self-medicate insomnia Enjoy euphoria Diversion Snorting

Source of misused prescription opioids SAMHSA, 2013

SAMHSA, 2013

Some will be able to stop Escalation Heroin is much cheaper Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Some will be able to stop Escalation Heroin is much cheaper Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Some will be able to stop Escalation Heroin is much cheaper Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Some will be able to stop Escalation Heroin is much cheaper Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Some will be able to stop Escalation Transition to heroin Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Some will be able to stop Escalation Transition to heroin Physical withdrawal Strong cravings Financially challenging Overdose risk increases dramatically Snorting Injecting

Illicitly produced fentanyl Cheap Widely available Incorporated into heroin Counterfeit tablets Many patients have no idea they are using it

Illicitly produced fentanyl Cheap Widely available Incorporated into heroin Counterfeit tablets Many patients have no idea they are using it

Illicitly produced fentanyl Cheap Widely available Incorporated into heroin Counterfeit tablets Many patients have no idea they are using it

Key Points Drug overdoses: now the leading cause of accidental death Overdose deaths linked to increase in opioid prescriptions Drug diversion Most common source: family and friends Most of these prescriptions come from a single doctor Recreational use Some individuals will escalate Some of them even up to IV heroin

Key Points Drug overdoses: now the leading cause of accidental death Overdose deaths linked to increase in opioid prescriptions Drug diversion Most common source: family and friends Most of these prescriptions come from a single doctor Recreational use Some individuals will escalate Some of them even up to IV heroin

Key Points Drug overdoses: now the leading cause of accidental death Overdose deaths linked to increase in opioid prescriptions Drug diversion Most common source: family and friends Most of these prescriptions come from a single doctor Recreational use Some individuals will escalate Some of them even up to IV heroin

Key Points Drug overdoses: now the leading cause of accidental death Overdose deaths linked to increase in opioid prescriptions Drug diversion Most common source: family and friends Most of these prescriptions come from a single doctor Recreational use Some individuals will escalate Some of them even up to IV heroin