1. Advancing Prevention, Treatment, and Recovery in Opioids and other Substance Use Disorders (SUD)
Jeffrey Coady, Psy.D., ABPP
CAPT, United States Public Health Service
SAMHSA Regional Administrator (5)
The Triple Threat: HIV, Hepatitis C and Opioids
June 25, 2019 Chicago, IL

2. Today’s Presentation Addictions
What does the existing data tell us about addictions, HCV, and HIV
What actions can we take to advance prevention, treatment, and recovery?
What resources are available to implement the actions?
What have we not discussed?

3. Your Brain on Drugs in the 1980’s
Drugs of abuse change the brain, and new technologies are showing us how. Indeed we’ve come a long way from this primitive depiction of a “brain on drugs.”
NIDA

4. % in each age group who develop first-time dependence
Addiction Is a Developmental Disease that starts in Adolescence and Childhood
1.8%
1.8%
TOBACCO
1.6%
1.6%
CANNABIS
ALCOHOL
1.4%
1.4%
1.2%
1.2%
1.0%
% in each age group who develop first-time dependence
1.0%
0.8%
0.8%
0.6%
0.6%
0.4%
0.4%
Addiction usually begins in adolescence, thus early prevention is critical. This slide illustrates the age at which drug dependence is first diagnosed, which for tobacco, alcohol and marijuana, is typically in adolescence or early adulthood. Much of the research supported by NIDA is aimed at preventing drug use from ever starting. This research ranges from highly complex molecular and imaging studies to devising effective messages that “speak” to young people.
0.2%
0.2%
0.0%
0.0% 5 5 10 10 15 15 21 21 25 25 30 30 35 35 40 40 45 45 50 50 55 55 60 60 65 65
Age
Age at tobacco, alcohol, and cannabis dependence per DSM IV
National Epidemiologic Survey on Alcohol and Related Conditions, 2003.

5. Addiction Dysregulates Brain Circuits
ACG
PFC
OFC
SCC
Hipp
Amyg
NAcc VP
EXECUTIVE FUNCTION
INHIBITORY CONTROL
REWARD/
PLEASURE
LEARNING/
MEMORY
MOTIVATION/
DRIVE
There is often significant stigma against people with addictions. People think of this as a result of a moral failure or weak will. But research has shown that addictions are brain disorders that result from changes in multiple brain circuits including those that oversee
Maureen Boyle, Ph.D., NIDA

6. Dopamine D2 Receptors are Decreased by Addiction
Cocaine
Meth
DA D2 Receptor Availability
Repeated drug exposure also changes brain function. Positron emission tomography (PET) images show similar changes in brain dopamine receptors resulting from addiction to different substances. Dopamine D2 receptors are one of five types of receptors that bind dopamine in the brain. The brain images on the left are those of controls, while those on the right are from individuals addicted to cocaine, methamphetamine, alcohol, or heroin. The striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating numerous D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating lower levels of D2 receptors. This reduction likely stems from repeated over-stimulation of the dopamine receptors. Brain adaptations such as this contribute to the compulsion to abuse drugs.
Alcohol
Heroin
Control
Addicted

7. control cocaine use disorder
Low D2 Receptors Lead to Decreased Frontal Activity
Striatum
Volkow et al., AJP 158(3): , 2001.
D2 receptors
control cocaine use disorder
Research has also shown that the decrease in D2 receptors seen in addiction is associated with decreased activity in the frontal cortex. Which is part of the changes in brain circuits that underlie addiction – which I’ll talk about more in a moment
Source: Maureen Boyle, Ph.D., NIDA

8. GO STOP Addicted Brain Non-Addicted Brain Control Drive Memory
frontal cortex
Saliency
NAc
Memory
Amygdala
Control
Non-Addicted Brain
Addicted Brain
STOP GO
In the non-addicted brain your circuits are able to balance your interest in a substance with your long term goals to make reasonable decisions about how to behave, you can stop yourself from taking the drink or doing the drug. But when someone develops an addiction their brain sees the drug as more valuable than it is leading to an increased drive to do the drug, and the circuits that control decision making and impulse control are weakened so it’s much harder to stop yourself from taking the drug even when you know there will be negative consequences.
Maureen Boyle, Ph.D., NIDA

9. Mental and Substance Use Disorders in America: NSDUH 2017
PAST YEAR, 2017, 18+
Among those with a substance use disorder approximately:
3 IN 8 (36.4%) struggled with illicit drugs
3 IN 4 (75.2%) struggled with alcohol use
1 IN 9 (11.5%) struggled with illicit drugs and alcohol
Among those with a mental illness approximately:
1 IN 4 (24.0%) had a serious mental illness
3.4%
(8.5 MILLION)
18+ HAD BOTH substance use disorder and a mental illness
7.6%
(18.7 MILLION)
People aged 18 or
older had a
substance use disorder
18.9%
(46.6 MILLION)
People aged
18 or older had a
mental illness
56.8 million adults
are affected either by a
mental disorder or
substance use disorder.
.4%
.3%
.2%

10. Nonmedical Use of Prescription Opioids Significant Risk Factor for Heroin Use
3 out of 4 people who used heroin in the past year misused prescription opioids first
7 out of 10 people who used heroin in the past year also misused prescription opioids in the past year
2017: 2.1 million with opioid use disorder
Source: Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. (2013). Slide credit – Grant Baldwin, CDC

11. Sources of Where Pain Relievers Were Obtained for Most Recent Misuse Among People Who Misused Prescription Pain Relievers
PAST YEAR, 2017, 12+

12. Opioid Related Deaths

13. What Does the Existing Data Tell Us?
Only 55% of those who need treatment for heroin use disorder and 21% of those who need treatment for prescription pain reliever use disorder get treatment.
Heroin and illicit opioid pills contaminated by fentanyl and other potent opioids account for the majority of overdose deaths
Prescription Opioid relievers account for most of the opioid misuse/use disorders that exist in the U.S.
Overprescribing and lack of public and patient education/awareness of the addictive potential and danger of prescription opioid misuse, are a major part of the problem.
Additionally, stigma, lack of resources, lack of providers and lack of evidence-based treatment availability/community recovery supports continue to be contributing factors of the opioid crisis.

14. Substance Use and the LGBT Community
40 percent of LGB adults had used illicit drugs in the past year. Comparatively, 18 percent of all adults had used illicit drugs in the past year
In the past year, 10.5 percent of LGB adults had misused prescription pain relievers compared to 4.5 percent of all adults who had misused prescription pain relievers.
In the past year, 0.9 percent of LGB adults used heroin compared to 0.4 percent of all adults who used heroin.

15. Despite Great Need Treatment Gaps Remain Vast
PAST YEAR, 2017
From 2004 to 2015, the number of buprenorphine visits rose from 0.04% to 0.36% of all ambulatory visits, representing 13.4 million visits between 2012 and 2015.
Buprenorphine prescription was received at considerably more visits by white patients than patients of other races/ethnicities
Black patients had statistically significantly lower odds of receiving buprenorphine prescription at their visits
Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. Published online May 08, doi: /jamapsychiatry

16. What does the existing data tell us about HCV and drug use?

17. Hepatitis C and Injection Drug Use

18. Hepatitis C and Injection Drug Use
With increased rates of opioid injection, there have also been increases in acute Hepatitis C infection related hospital admissions across the country.
Rates of opioid injection—especially injection of prescription opioid pain relievers, as well as heroin—and acute hepatitis C virus infections increased most dramatically from 2004 to 2014 among younger Americans (ages 18-39).
There were also sharp increases among whites and among women.
Increases in prescription opioid sales, opioid overdose deaths, and HCV are indications for incident of HIV.
And as infections increase among young women, so has the rate of hepatitis C among pregnant women—placing a new generation of Americans at risk.
Support drug treatment and recovery services, including medication-assisted treatment, which can help people who inject drugs stop injecting – the primary risk behavior leading to new hepatitis C virus infection.
Provide a range of testing, treatment and prevention services for hepatitis C and other infectious diseases, including hepatitis B and HIV

19. Drug Overdoses and Hepatitis C: Interconnected Epidemics
Drug Overdose Death Rates
Reported New HCV Infections
SOURCE: CDC/NCHS Data Visualization Gallery 2015
SOURCE: CDC National Notifiable Disease Surveillance System

20. What does the existing data tell us about HIV and drug use?

21. Injection Drug Use-Associated HIV is Increasing
Increase of 4% in 2015

22. HIV and Substance Use Disorders
According to CDC in 2016, persons who injected drugs represented “9% (3,425) of the 39,782 diagnoses of HIV in the United States in 2016 (2,224 cases were attributed to injection drug use and 1,201 to male-to-male sexual contact and injection drug use).”
Highlighted by recent outbreaks such as Scott County (Indiana). From November November 2015, 181 cases of HIV with about 87 percent using opioids (oxymorphone).
Links to hepatitis and other communicable diseases as well as HIV
Often co-occurring mental health conditions
Source:

23. Opioid, HIV, and HCV Epidemics Ignite in a Rural Indiana Community
• 223 people with HIV
• 90% have HCV coinfection
• 5% adults with HIV (population 3,143)
• Over $100 million in lifetime medical costs
• Outbreak stopped
Credit: Tyler Stewart / Associated Press

24. What are the solutions?

25. HHS Five-Point Opioid Strategy
HHS Opioid Strategy
HHS Five-Point Opioid Strategy
Strengthening public health surveillance
Advancing the practice of pain management
Improving access to treatment and recovery services
Targeting availability and distribution of overdose-reversing drugs
Supporting cutting-edge research 1 2 3 4 5

26. Strategies to Address the Opioid Epidemic
Community
Prevention
Crisis
Services
Clinical
Practice
Recovery
Support
Workforce
Strategic Planning
Community & Provider Education
Harm Reduction
Medication Disposal
Naloxone distribution & education: 1st responders, patients, family
ER overdose education (MAT initiation)
Detoxification
Link ER/Detox to treatment
CDC Pain Management Guidelines
Screening & Assessment
Medication Assisted Treatment
SUD Levels of Treatment
PDMP
Tele-Health
Access to Health Care
Safe & Affordable Housing
Education & Employment
Social & Community Connections
Data 2000 Waiver (MD/PA/APRN)
Clinician Support & Continuing Education
Recruitment & Retention Plans
Integrated Care Competencies
Peer Recovery
Prevention Strategies:
Syringe Exchange Programs;
PSAs;
National Drug Take Back Day events
Crisis Service Strategies:
Distributing Naloxone to LE/EMT/Schools/Occupational Health Facilities;
Implementing Fentanyl Safety Recommendations;
Peer Recovery Specialists working in EDs to link patients to treatment immediately post overdose
Clinical Practice Strategies:
Implementing SBIRT;
Co-prescribing Naloxone with high risk patients in chronic pain treatment;
Implementing Hub and Spoke Model of Care
Recovery Strategies:
Sober-Living Facilities;
Supported Employment and Education Programs;
Recovery High Schools and Colleges
Workforce Strategies:
DATA 2000 Waiver Training;
NHSC/IHS;
AHRQ Integrated Care Competencies;
Standardizing core competencies for students: BHWET/NHSC

27. Comprehensive Community Action
Identify areas of need, mobilize community including health and law enforcement sectors
• Comprehensive syringe service programs (SSPs)
• Substance use treatment; naloxone
• HIV and hepatitis testing, link to treatment
• Sterile syringes
• SSPs prevent HIV and HCV infection and do not increase drug use or crime
• People who used SSP 5 times more likely to enter drug treatment and 3 times more likely to stop injecting
• Cost saving
HOI Commonwealth Dept Health Aging, 2002; MacArthur G; BMJ Aspinall E J et al. Int J. Epidemiology, 2014; Hagan J Sub Abuse Treatment 2000; Harm reduction coalition

28. Leveraging Existing Services
Community health centers, HIV and STD programs, and clinical services in all 50 states
• Screen and refer people to substance use treatment
• Test and treat for viral hepatitis, HIV
• Viral hepatitis programs supported in 46 states
• Enhanced surveillance data from 14 states that represent >70% of the HBV/HCV cases in US
• Use acute HCV infections as indicator of need for rapid community action
Credit: Tyler Stewart / Associated Press

29. MAT: Standard of Care for Opioid Use Disorders
Medicated-Assisted Treatment (MAT) is the use of FDA- approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders.
MAT for Opioid Use Disorder
MAT for Alcohol Use Disorder
MAT for Smoking

30. MAT: Standard of Care for Opioid Use Disorders
MAT Treatment
Methadone
Buprenorphine/Naloxone
Qualifying physicians can treat up to 30, 100 or 275 patients
Qualifying NP’s and PA’s can treat up to 30 or 100 Suboxone
Injectable naltrexone
Medication treatment while in DOC; referral to ongoing care for OUD on release
Comparison of opioid overdose deaths first 6 months of 2016 vs. 2017: 61% reduction in opioid-associated overdose deaths upon release from incarceration
Overall 12% reduction in opioid overdose deaths in Rhode Island (2017)
Importance of MAT and warm handoff to outpatient providers
Green TC, et al. JAMA Psychiatry, 2018

31. Efficacy of Medications
After buprenorphine became available in Baltimore, heroin overdose deaths decreased by 37%.
Source: Maureen Boyle, Ph.D., NIDA

32. Benefits of MAT Reduces all cause mortality Reduces HIV risk
Improves adherence to medical treatment
Improves social function
Decreases criminal behaviors
Decreases drug use
Schwartz R Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, American Journal of Public Health May2013, Vol 103, No. 5.pp
Soyka M. et al. Criminal Behavior in Opioid-Dependent Patients Before and During Maintenance Therapy: 6-year Follow-Up of a Nationally Representative Cohort Sample J Forensic Sci, November 2012, Vol. 57, No. 6
Fullerton, C. Assessing the Evidence: MAT with Methadone.
Psychiatric Services in Advance, November 18, 2013; doi: /appi.ps
Modesto-Lowe et al.: Methadone Deaths in Pain and Addiction Populations. JGIM 2012 Apr; 25(4): 305-9
Gibson A. Exposure to Opioid Maintenance Treatment Reduces Long-term Mortality. Addiction, 103, 462–468
Bell J, Zador D; A Risk-benefit analysis of methadone maintenance treatment. Drug Safety 2000 Mar; 22 (3):
Springer S Retention on Buprenorphine is Associated with High Levels of Maximal Viral Suppression among HIV-Infected Opioid Dependent Released Prisoners. PloS ONE May 2012 Volm 7 No. 5
Scharz R Retention on buprenorphine treatment reduces emergency department utilization, but not hospitalization, among treatment-seeking patients with opioid dependence. Journal of Substance Abuse Treatment 43(2012)
Mattick RP, Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Review)
Copyright © 2014 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Marsch L, The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a
meta-analysis. Addiction (1998) 93(4), 515± 532

33. Benefits of MAT: Suicide Prevention
Suicide is the leading cause of death among people with substance use disorders (SUDs).
Compared with the general population, people treated for alcohol abuse or dependence are at about a 10x greater risk for suicide. (Wilcox, et al., 2004)
Those who inject drugs are at about a 14x greater risk for suicide. (Wilcox, et al., 2004)
The number of substances used seems more predictive of suicide than the types.
BF headline, increased size from 32 to 44 point; capitalized and added break after “Between”; increased size of body text from 26 to 32 point

34. Expertise

35. Adverse Childhood Experiences

36. Trauma Informed Care
SAMHSA’s Concept of Trauma 3-E’s : Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and/or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, and/or spiritual well-being
Adoption of principles and practices that promote a culture of safety, empowerment, and healing.
Based on what we know about the prevalence and impact of trauma, it is necessary to ensure widespread adoption of trauma-informed care.
Bi directional relationship with addictions

37. SBIRT Learning Tool – Brief Intervention Steps

38. Motivational Interviewing
Ambivalence
Change Talk
Sustain Talk
“Client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”
Miller & Rollnick, 1992

39. Recovery Oriented System of Care
Arthur Evans

40. Creating and Reinforcing Recovery Capital
Essential Ingredients for Sustained Recovery:
Safe and affordable place to live
Steady employment and job readiness
Education and vocational skills
Life and recovery skills
Health and wellness
Recovery support networks
Sense of belonging and purpose
Community and civic engagement

41. Creating and Reinforcing Recovery Capital
Often, a Need to Address:
Legal issues
Expunging criminal records
Financial status: debt, taxes, budgeting, etc.
Restoring revoked licenses: professional, business, driver’s
Regaining custody of children
Developing relationship and parenting skills
Developing recovery support networks and community connections

42. Resources

43. Resources (hhs.gov/opioid)

44. SAMHSA: Technical Assistance and Training Programs in a Variety of Formats
Evidence-Based Practice Repository in NMHSUPL
National Technical Assistance/Training Centers:
State Targeted Response to Opioids, Providers’ Clinical Support System for Medication Assisted Treatment, Clinical Support System for Serious Mental Illness, National Child Traumatic Stress Network, National Center on Substance Abuse and Child Welfare, Center for Integrated Health Services, Veterans, GAINS (Criminal Justice), Disaster, Social Inclusion/Public Education, SOAR, Suicide Prevention, Eating Disorders, Privacy
Combined Efforts at the Regional, State, and Local Levels Oriented to All Health Professionals
Regional Substance Abuse Prevention, Addiction, Mental Health/School Based Services Collaborating Technology Transfer Centers
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
National Hispanic/Latino TTC
National American Indian/Alaska Native TTC

45. Providers Clinical Support System Training
Provider’s Clinical Support System – Medication Assisted Treatment (PCSS-MAT) provides waiver trainings, online CME courses, and no-cost clinical coaching/mentoring to support evidence-based treatment of substance use disorders and co-occurring mental disorders.

46. National Recovery Month

47. Prescription Drug Take Back Day: October 26, 2019

48. THANK YOU FOR WHAT YOU DO IN YOUR COMMUNITY TO HELP OTHERS
Jeffrey Coady, Psy.D., ABPP
CAPT, United States Public Health Service
SAMHSA Regional Administrator