OPIOIDS- POPPIES AND
BEYOND
FACULTY DISCLOSURE
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LEARNING OBJECTIVES
• PLACE THE OPIATES (OPIOIDS) IN PROPER PERSPECTIVE
HISTORICALLY
• REVIEW THE KEY DEVELOPMENTS IN OPIOID
REFINEMENTS AND USES
• LEARN THE BASIC PHARMACOLOGY OF OPIOIDS
RELATED TO THEIR THERAPEUTIC AND ADDICTIVE
PROPERTIES
I've seen the needle
and the damage done
A little part of it in everyone
But every junkie's
like a settin' sun.
Neil Young
THE POPPY HAS BEEN
AROUND A LONG TIME
• USE AND CULTIVATION BEGAN IN THE MIDDLE EAST
• SPREAD ACROSS ANCIENT CIVILIZATIONS FAIRLY RAPID
• METHODS TO ENHANCE AND PURIFY FOLLOWED
• THEN CAME NEW METHODS OF ADMINISTRATION
•
POPULATIONS OF CONSUMERS DEVELOPED
• AND THE MONOPOLIES AND RIVALRIES GREW
• 3400 B.C. ‐ 300 A.D.
The earliest reference to opium growth and use is in 3400
B.C. when the opium poppy was cultivated in lower
Mesopotamia. The Sumerians referred to the opium poppy
as the “Joy Plant” and would pass the plant and its euphoric
effects on to the Assyrians, who in turn passed it on to the
Egyptians.
• 330 B.C.
Alexander the Great introduces opium to the people of
Persia and India
MODIFIED YEAST PRODUCE OPIATES FROM SUGAR
SCIENCE MAGAZINE AUGUST 13, 2015
THE EUROPEANS GO EAST
• 1020
AVICENNA
OF
PERSIA TEACHES THAT OPIUM IS "THE MOST POWERFUL OF STUPEFACIENTS.“
• 1300S
OPIUM DISAPPEARS FOR TWO HUNDRED YEARS FROM EUROPEAN HISTORICAL RECORD.
OPIUM HAD BECOME A TABOO SUBJECT FOR THOSE IN CIRCLES OF LEARNING DURING THE
HOLY INQUISITION. IN THE EYES OF THE INQUISITION, ANYTHING FROM THE EAST WAS
LINKED TO THE DEVIL.
• 1500
THE PORTUGUESE, WHILE TRADING ALONG THE EAST CHINA SEA, INITIATE THE SMOKING
OF OPIUM. THE EFFECTS WERE INSTANTANEOUS AS THEY DISCOVERED BUT IT WAS A
PRACTICE THE CHINESE CONSIDERED BARBARIC AND SUBVERSIVE
“AMONG THE REMEDIES WHICH IT HAS
PLEASED ALMIGHTY GOD TO GIVE TO
MAN TO RELIEVE HIS SUFFERINGS,
NONE IS SO UNIVERSAL AND SO
EFFICACIOUS AS OPIUM.”
•
THE MARKETS GROW AND BECOME LUCRATIVE
• 1600S
RESIDENTS OF PERSIA AND INDIA BEGIN EATING AND DRINKING OPIUM MIXTURES FOR
RECREATIONAL USE. PORTUGUESE MERCHANTS CARRYING CARGOES OF INDIAN OPIUM
THROUGH MACAO DIRECT ITS TRADE FLOW INTO CHINA.
• 1700
THE DUTCH EXPORT SHIPMENTS OF INDIAN OPIUM TO CHINA AND THE ISLANDS OF
SOUTHEAST ASIA; THE DUTCH INTRODUCE THE PRACTICE OF SMOKING OPIUM IN A
TOBACCO PIPE TO THE CHINESE.
• 1773
EAST INDIA COMPANY ASSUMES MONOPOLY OVER ALL THE OPIUM PRODUCED IN
BENGAL, BIHAR AND ORISSA. WARREN HASTINGS INTRODUCES SYSTEM OF CONTRACTS.
CONTRACTS FOR DEALING IN OPIUM WERE AWARDED THROUGH AUCTION.
THE PRIMARY RISK FACTORS FOR
ADDICTION- NO MATTER WHICH CLASS OF
DRUG
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Dopamine Pathways – Pleasure pathways
striatum
frontal
cortex
hippocampus
alcohol
substantia
nigra/VTA
cocaine
nucleus
heroin
nicotine
accumbens
amphetamines
opiates
THC
PCP
ketamine
heroin
alcohol
benzodiazepines
barbiturates
REWARD CENTERS OF THE BRAIN
BETTER DELIVERY SYSTEMS
• 9TH CENTURY AD: THE EGYPTIAN SURGEON AMMAR IBN 'ALI AL-MAWS' CREATED A
SYRINGE IN THE 9TH CENTURY USING A HOLLOW GLASS TUBE, AND SUCTION TO REMOVE
CATARACTS
• 1650: BLAISE PASCAL INVENTED A SYRINGE (NOT NECESSARILY HYPODERMIC) AS AN
APPLICATION OF WHAT IS NOW CALLED PASCAL'S LAW
• 1844: IRISH PHYSICIAN FRANCIS RYND INVENTED THE HOLLOW NEEDLE AND USED IT TO
MAKE THE FIRST RECORDED SUBCUTANEOUS INJECTIONS, SPECIFICALLY A SEDATIVE TO
TREAT NEURALGIA
• 1853: CHARLES PRAVAZ AND ALEXANDER WOOD
DEVELOPED A MEDICAL HYPODERMIC
SYRINGE WITH A NEEDLE FINE ENOUGH TO PIERCE THE SKIN.
• ALEXANDER WOOD EXPERIMENTED WITH INJECTED MORPHINE TO TREAT NEURALGIA.
HE AND HIS WIFE BECAME ADDICTED TO IT. HIS WIFE WAS THE FIRST WOMAN TO DIE OF
AN INJECTED DRUG OVERDOSE?* *MAY BE A MYTH
REFINEMENTS MADE IN PURITY AND
POTENCY
• 1803
FRIEDRICH SERTÜRNER
PADERBORN, GERMANY DISCOVERS THE ACTIVE INGREDIENT OF OPIUM BY
DISSOLVING IT IN ACID THEN NEUTRALIZING IT WITH AMMONIA. THE RESULT: ALKALOIDS – PRINCIPIUM
SOMNIFERUM OR MORPHINE.
OF
• PHYSICIANS BELIEVE THAT OPIUM HAD FINALLY BEEN PERFECTED AND TAMED. MORPHINE IS LAUDED AS
"GOD'S OWN MEDICINE" FOR ITS RELIABILITY, LONG-LASTING EFFECTS AND SAFETY.
• 1816
JOHN JACOB ASTOR OF NEW YORK CITY JOINS THE OPIUM SMUGGLING TRADE. HIS AMERICAN FUR
COMPANY PURCHASES TEN TONS OF TURKISH OPIUM THEN SHIPS THE CONTRABAND ITEM TO CANTON ON
THE MACEDONIAN. ASTOR WOULD LATER LEAVE THE CHINA OPIUM TRADE AND SELL SOLELY TO
ENGLAND.
CHASING THE DRAGON
BUSINESS GROWS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
New Non-medical Users of Pain Relievers
1965-2002
Thousands of New Users
3,000
2,500
All Ages
2,000
1,500
Aged 18
or Older
1,000
Aged
Under 18
500
0
1965
1970
1975
1980
1985
1990
Source: 2003 NSDUH, SAMHSA
1995
2000
INCREASED ACCESS TO OPIOIDS
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•
ALL CONTROLLED SUBSTANCE RX’S 2011
Cabinet for Health and
Family Services
Drugs of reward in top 25 by $-KY Medicaid
$140,000,000
$120,000,000
$100,000,000
$80,000,000
$60,000,000
$40,000,000
$20,000,000
$Buprenorphine all
Stimulants (MethylPh/Vyvanse)
Hydrocodone/APAP
2013
2014
2015
Gabapent/Pregabalin
all above
IMPACT IN KENTUCKY
OPIOIDS OF VARIOUS
TYPES
•
•
•
•
OPIOID INTOXICATION
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THE EYES AND OPIOIDS
SOPHISTICATED MARKETING
PATHS OF TREATMENT
WE NEED ALL THE TOOLS WE CAN GET, BUT WE
NEED TO BE VIGILANT WE DON’T REPEAT HISTORY
THE THREE MISSING ELEMENTS IN THE TREATMENT
OF SUBSTANCE USE DISORDERS: LESSONS FROM THE
PHYSICIAN HEALTH PROGRAMS
ROBERT L. DUPONT , MARVIN D. SEPPALA & WILLIAM L. WHITE -OCT. 2015 J OF ADDICTIVE DISEASE
• 1) THE DEFINITION OF LONG-TERM RECOVERY AS THE GOAL OF ALL
TREATMENT AND POST-TREATMENT INTERVENTIONS
• 2) THE PROVISION OF SUSTAINED POST-TREATMENT MONITORING AND
PROFESSIONAL AND PEER SUPPORT, INCLUDING DRUG TESTING
• 3) THE INSISTENCE BY OTHERS AROUND THE PATIENTS ON SUSTAINED
ABSTINENCE AS CRUCIAL FOR THOSE SUFFERING FROM MODERATE TO SEVERE
AND PROLONGED SUDS
THANKS
GREG L. JONES, MD