Responding to the
Opioid Addiction Epidemic
Andrew Kolodny, M.D.
Chief Medical Officer
Phoenix House Foundation
New York, NY
The Opium Poppy
Papaver Somniferum
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Crude Opium Latex on Poppy Head
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Opioids
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•
•
•
•
•
•
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Morphine
Naturally occurring opioidsCodeine
also called opiates
Thebaine
Diacetylmorphine (Heroin)
Hydrocodone (Vicodin)
Oxycodone (Oxycontin)
Oxymorphone (Opana)
Hydromorphone (Dilaudid)
Semi-synthetic
opioids
Prior Opioid Addiction Epidemics
1.
Late 1800s: Morphine
• Mainly middle class
• Female > Male
2.
Early 1900s: Heroin (pharmaceutical grade)
• First generation Italians, Jews, Irish
• Male > Female
3.
1950s-1970s- Heroin (illicit)
• African American/Latinos
• Male > Female
Governor Shumlin devotes entire state of the state
speech to Vermont’s opioid addiction epidemic
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Unintentional Drug Overdose Deaths
United States, 1970–2007
10
Death rate per 100,000
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38,329 drug overdose deaths in 2010
8
7
6
5
4
Cocaine
3
2
Heroin
1
0
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Year
National Vital Statistics System, http://wonder.cdc.gov
Drug Overdose Deaths by Major Drug Type,
United States, 1999–2010
Opioids
Heroin
Cocaine
Benzodiazepines
18,000
16,000
Number of Deaths
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
2009
2010
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
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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)
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Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011
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Heroin admissions, by age group & race/ethnicity: 2001- 2011
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Unintentional overdose deaths involving opioid
analgesics parallel per capita sales of opioid
analgesics in morphine equivalents by year,
U.S., 1997-2007
14000
*
800
12000
700
10000
600
8000
500
Number of
6000
Opioid sales
(mg/person)
Deaths
400
300
4000
200
2000
100
0
0
'97
'98
'99
'00
'01
'02
'03
'04
'05
Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS
* 2007 opioid sales figure is preliminary.
'06
'07
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Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010
Opioid Sales KG/10,000
Opioid Deaths/100,000
2000
2003
Opioid Treatment Admissions/10,000
7
6
Rate
5
4
3
2
1
0
1999
CDC. MMWR 2011
2001
2002
2004
2005
Year
2006
2007
2008
2009
2010
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20
Dollars Spent Marketing OxyContin (1996-2001)
Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and
Efforts to Address the Problem.”
Industry-funded “education” emphasizes:
• Opioid addiction is rare in pain patients.
• Physicians are needlessly allowing patients to
suffer because of “opiophobia.”
• Opioids are safe and effective for chronic pain.
• Opioid therapy can be easily discontinued.
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Industry-funded organizations
campaigned for greater use of opioids
• Pain Patient Groups
• Professional Societies
• The Joint Commission
• The Federation of State Medical Boards
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“The risk of addiction is much less than 1%”
Porter J, Jick H. Addiction rare in patients treated
with narcotics. N Engl J Med. 1980 Jan
10;302(2):123
Cited 824 times (Google Scholar)
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N Engl J Med. 1980 Jan 10;302(2):123.
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“I think that after 20 years of a failed
experiment that there are not many people
supporting this except for the die-hards and
the pharmaceutical industry.”
Jane C. Ballantyne, MD FRCA
Professor, Univ. of Washington
Source: New York Times, April 9, 2012. “Tightening the Lid on Pain
Prescriptions”.
The Emperor’s New Paradigm:
Patient Selection, Risk Stratification & Monitoring
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Urine Tox Results in Chronic Pain Patients on Opioid Therapy
Source: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug
use in the chronic pain population. Popul Health Manag. 2009;12(4):185–190.
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Controlling the epidemic:
A Three-pronged Approach
• Prevent new cases of opioid addiction.
• Treatment for people who are already
addicted
• Supply control- Medical board & law
enforcement efforts to reduce overprescribing and black-market availability.
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Opioid manufacturers continue to advertise opioids as
safe and effective for chronic pain.
How the opioid industry Frames the Problem
Source: Slide presented by Lynn R. Webster MD at FDA meeting on
hydrocodone upscheduling, January 25th, 2013.
Drug overdose death rates by intent by age
group, US, 2008
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This is a false dichotomy
Aberrant drug use behaviors are common in pain patients
63% admitted to using opioids for
purposes other than pain1
Pain Patients
“Drug Abusers”
35% met DSM V criteria for
addiction2
92% of opioid OD decedents
were prescribed opioids for
chronic pain.
1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving
Daily Opioid Therapy. J Pain 2007;8:573-582.
2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:
comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.
3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of
Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.
Frequently Discussed Interventions
• Abuse-deterrent formulations
• Expanding access to naloxone
• Expanding access to medication assisted
treatment
• PDMP-based interventions
• Mandatory prescriber education
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Buprenorphine Treatment
• Partial agonist
– Weaker effects
– Safer to use
• Long duration of action
• Milder withdrawal symptoms
Full Opioid Agonists
Buprenorphine- A Partial Agonist
Summary
• We are in the midst of the worst drug
epidemic in U.S. history.
• To end the epidemic we need to:
– PREVENT new cases of opioid addiction
– TREAT people who are already addicted
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Please visit
www.supportPROP.org
@andrewkolodny
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