1. Ohio’s Abuse Epidemic: Treatment Can Work
Rehabilitation Care Group
Nino DiIullo, MD and Karl Valentine, MD

2. Presentation Overview
Review statistics on drug overdose deaths in Ohio
Discussion of factors contributing to this problem
Anatomy of addiction
State response to addiction epidemic
How Rehabilitation Care Group treats this problem

3. The Epidemic of Drug Abuse
Drug abuse has become a major national problem
In 2013, nearly 44,000 people died from drug overdoses
The number of deaths has more than doubled since 1999
Ohio has the 8th highest drug overdose rate in the U.S.
The leading cause of accidental death in Ohio is overdose
The number of deaths has increased 440% since 1999
On average, 6 Ohioans die each day from drug overdose
The cost to the community isn’t just personal
More than $2.5 billion is lost each year due to drug overdose fatalities
Non-fatal, drug poisonings requiring hospitalization cost $31.9 million

6. Contributing Factors: Social and Environmental
40% – 60% of vulnerability to addiction can be attributed to genetic and environmental factors
Low socioeconomic group and lack of education can increase abuse, but addiction ranges across all social classes.
Poor parental support contributes to addiction among youths
Mental illness also significantly increases risk of drug abuse

7. Contributing Factors: Drug Availability
Pain relief laws passed in 1997 expanded the usage of potent pain medicine in response to recognition of pain as 5th vital sign
2 out of 3 patients who visit a doctor leave with at least one prescription for medication
More than $234 billion was spend on prescription drugs in 2008, almost 6 times the amount spent in 1990
Perceived legitimacy of prescription drugs
Increasing availability of drugs on the internet

9. Contributing Factors: Upsurge in Heroin
Legislative changes in 2012 helped shut down the “pill mills” and restrict access to prescription opiates
Price of prescription drugs on the black market skyrocketed
Heroin has now become the cheap drug of choice
Number of heroin abuse cases is now on the rise

11. Contributing Factors: Youth Addiction
More than 1 in 5 Ohio high school students reported using a prescription drug without a doctor’s authorization in 2011
49% of these students used narcotic pain relievers
Every day 2,700 teens abuse a prescription drug for the first time.
8 out of 10 who misuse prescription drugs get these drugs from friends or family

12. Anatomy of Addiction

13. Anatomy of Addiction
The limbic system is highly interconnected and the structures are essential not only for learning and memory but also for the emotional context and the affective right and wrong response to learned association.
Many drugs of abuse have their sites of action within the limbic system and the neurochemistry within the structures is altered during the addiction process.
Dopamine plays a central role in reward and drug addiction.

14. Anatomy of Addiction
The neuroanatomy of addiction and human subjects has documented metabolic changes noted on PET scan.
Addiction results in deeply ingrained memories capable of creating intense urges and patient exposed to triggers – emotional or sensory, after years of log abstinence.

15. Biology of the Brain 1
Non-Opioid Dependent Brain
Opioid Dependent Brain
PET scan images show changes in brain function caused by opioid dependence. The lack of red in the opioid-dependent brain shows a reduction in brain function in these regions.

16. Biology of the Brain2

17. Biology of the Brain3

18. Biology of the brain
Drug addiction is a disease of the brain associated with abnormal behavior.
Drugs of abuse provide longer and larger highs
5-10 times increases in dopamine to the brain than natural rein forcers as an food or sex.
Opioid Dependence is a Chronic Brain Disease shown to cause: 1
Pervasive changes in cognitive and drug-rewarding circuits 1
Significant altercations in the neurochemical, molecular and cellular levels 1
Changes to brain structure and function that persist long aver the drug has ceased 1

20. Dopamine Pathways and Addiction

22. State Response Legislation – HB 93
Addresses the Physician component
Licensing of pain management clinics
Sets dispensing limits
Updated OARRS rules
GCOAT – Governor’s Cabinet Opiate Action Team
Addresses the misuse, abuse and overdose from prescription opioids
Treatment
Education
Enforcement
Recover Supports
Professional Education

23. How We Fit In Rehabilitation Care Group – RCG
Established, outpatient treatment program for opioid addiction
Confidential, understanding, no judgment environment
Licensed Physicians Educated in Substance Abuse
Our Two Step Approach
1. Address the three C’s
2. Address the psychosocial and environmental factors influencing the individual’s decisions

24. Step One Address the 3 C’s Recovery with the assistance of Vivitrol
Control
Craving
Continued use
Recovery with the assistance of Vivitrol

25. Vivitrol What is Vivitrol? How does Naltrexone work?
Extended-release dose of naltrexone
Medicine provided in a single, monthly shot by a medical professional
Used for both alcohol and opioid dependence treatment.
How does Naltrexone work?
Opioid antagonist that has the highest binding affinity to mu-opiod receptors
Creates a 1 month opioid blockade
Does not stimulate the dopamine reward pathway
Not addictive and does not lead to physical dependence or withdrawal
Very effective blocker for both alcohol and mu-receptors

26. Opioid Effect on the Brain

27. Naltrexone’s Effect on mu-receptors

28. Naltrexone vs. Buprenorphine
 Opioid Antagonist vs. Agonist
Buprenorphine has a very strong affinity to the opioid mu receptor. It completely activates the receptor to prevent other opioids from activating it.
Naltrexone blocks access to the opioid mu receptor. The receptors cannot activate because the naltrexone blocks opioid access to them.
Diversion risk
Buprenorphine is commonly taken daily so there is a risk of medicine being sold on secondary market
Extended-release naltrexone is administered in office, no chance of diversion
Control over Dosage
Buprenorphine is self-administered. Patients can vary their dosage by over or under administering medicine.
Vivitrol dosages are set and administered by doctor. Doctor would need to adjust dosage at monthly appointment.

29. Step Two Address the psychosocial and environmental factors
The What and The Why
In House, Licensed Counselors
IOP Counseling
Individual, Family and Group
Focus: Early recovery skills, relapse prevention, family education and social support
Continued Counseling
Family and Group
Focus: Identifying triggers, preventing relapse, the family role of recovery

31. Our Program Prescreening Induction Visit Follow Up Visits
All patients receive an initial phone consultation with an intake specialist
Educates them on our program
Determines if the program is a good fit for them
Induction Visit
First Visit – With Physician
Patient presents post-withdrawal or begins withdrawal protocol
First dose administered
Discharge upon stabilization
Follow Up Visits
Two weeks after induction
Monthly, thereafter

32. How we are different Commitment Compassion Education Understanding
We are committed to our patients and to their recovery
We ask our patients to commit to us
Compassion
Addiction doesn’t discriminate
Understand that addiction is different for everyone
Tailor our program to fit the needs of the patient
Education
Knowledge is power. The more prepared our patient, the better their chance at success
Understanding
There will be difficult times, there will be challenges – even setbacks
No judgment – even if relapse occurs

33. For Additional Information, please contact:
Nikki Williams, Clinic Manager
Dr. Karl Valentine, Medical Director
Dr. Nino DiIullo, Owner
Phone: (614)

34. References:
Slide 3: Data from
Slide 4: ODH Office of Vital Statistics*
Slide 5: 1) ODH Office of Vital , Statistics; 2) Ohio Department of Public Safety, Ohio Traffic Crash Facts*
Slide 6: 1) SAMHSA Treatment Episode Data Set (TEDS); 2) Drug Abuse Warning Network (DAWN); 3) National Survey of Drug Use in Households (NSDUH) *
Slide 8: Institute for Safe Medication Practices*
Slide 9: 1) WONDER (NCHS Compressed Mortality File, & ) 2) ODH Office of Vital Statistics, 3) Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999)*
Slide 10: DOJ, DEA, and ARCOS reports*
Slide 12: 1) WONDER (NCHS Compressed Mortality File, & ) 2) ODH Office of Vital Statistics, 3) Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999)*
Slide 13: 1) ODH, Ohio Youth Risk Behavior Survey; 2) SAMHSA’s National Survey on Drug Use; 3) SAMHSA’s National Survey on Drug Use*
Slide 17: A.D.A.M. Health Solutions. A.D.A.M Images. Retrieved from
Slide 18: Reckitt Benckiser Pharmaceuticals Inc., 2011, Evolving Treatment, Empowering Patients.
Slide 19: R., Fiellin, D., Miller, S. & Saitz, R. (2009). Principles of Addiction Medicine.
Slide 25: Image from
Images taken from Ohio Department of Health slideshow presentation: Ohio’s Prescription Drug Overdose Epidemic available at: