Second in 2017 Foundation Series on science in the society. The first lecture this year on the brain and video games was held in march and the third in september will be on meditation so please keep an eye out for the announcement date. The foundation is a Philanthropic Organization that supports Brain Research programs, publications and Educational Programs like this one. For the last five years, weve partnered with the foundation to present an annual lecture series on society and by my count this as the lecture in a series. We are grateful for the Dana Foundation support of the series and for the leadership in the series and our scientific responsibility human rights and law program. Thank you. Welcome. It seems to me hardly a day goes by there isnt a story i see either in a newspaper or o the n the evening news about the Opioid Crisis. And as i was thinking about that today, sure enough on the front page of the Washington Post is a story abouhas a story about he governors of maryland and virginia along with washington, d. C. As mayor are getting together to form a combined database to keep an eye on prescriptions and getting the drugs so its just another day. A few days somebody sent me something that said that. The opioid painkillers, 92 million sees a lot of that. I wanted to kno want you to knoa reception planned. So tonight we are going to look at and eagles eye view of the Opioid Epidemic and close in view from the institute of drug abuse to talk about possible treatment but the first speaker is a professor from the university of california San Francisco specializes in Community Medicine and treating diseases. He was a leader in the hiv aids epidemic so hes going to talk with us tonight at the scope of the problem. There is no mouse function is there . There we go. I cant even begin to talk until my slides are up. Hello, everyone. My perspective is one of trying to see ways towards increasing community health. Doctor drug Academic Affairs at him and sent him off to heroine and fentanyl. Im going to go through the epidemiological data comparing prescription pills with heroin with the epidemic curves and spend time talking about the manufactured fenc fentanyl. This is publicly available data. A little bit will come from my study from the National Institute of health and drug abuse. For the First Time Since 93 the death rate has gone up year over year. Here we have the two big elephant in the room that cancel each other out. But if we go to number four, unintentional injuries we see a bump up in 2014 to 2015. Weaver shot in 2011 to find out that two of the leading causes have crossed over with drug poisoning on the rise in Motor Vehicle accidents on the decline but this is good news and bad news in the drug epidemic. The number of deaths now have exceeded car accidents, gun violence and even hiv you can see here i apologize it is a steep rise up around 1993 and then a decline. We moved the epidemic to a crisis. Looking at hospitalization data this is the curve for the Opioid Epidemic. A dramatic rise in the 93 to about 2011 and some good news plateauing the proxy of the decline post 2011. This is based on the work that we are doing to restrict the practices. This is now an overdose on the dramatic increase up, just since 2008. The magnitude in this slide with a steep curve of concern yearoveryear no end in sight. Theres evidence that the number of users is rising coming from two paths. One is coming from opioid dependency finding heroine is not available and cheaper replacing the high level with a harrowing dependency and others are coming straight away now. The last few years with the availability has gone up. In vermont its not supposed to happen but they do. It is transitioning they used the term as early as 2012. One group would transition back and forth because they are treated equally. We also wrote a story about those that transition with all of the new and young users telling a story about how they started with pills and then moved over. There is some data on the group looking at comparing the demographics by age. The pay overdose problem is 2012 to 2014 data 50 to 64yearolds. Its no reason you want to show evidence for drug epidemic it is among younger people, there we have it. If we shift this over we see that transitioning of the overdose from year to year it goes down and you see from the bluetooth green is going up in that same 2012 to 2014. In the geographic region we see a difference. The opioid overdose is relatively even over a long time. How. We like to think that its worse in places like appalachia. There are differences in the use curves but to the eye they look west by region and that isnt true for heroine. Theyve had a problem that is highlighted with the gold aero from low levels to high levels of overdose with disparity that cannot be explained by the population at risk. So in addition to that story, we have to tell another. Lets talk about fentanyl. You dont go to a separate corner down the street and ask for a funny street name for this new drug called fentanyl. The heroine that you get if you were in that town in massachusetts for example coming you are going to get fentanyl contaminated heroine and the other is 100 times powerful as morphine by weight calculation. Weve had multiple waves of this in the past but the latest is much longer than the other waves and it began in the late 2013. It is philosophically manufactured fentanyl according to the dea. It is a booster of campaign considered a side event and it is now ubiquitous in the cocaine supply and this implies that there may be a future for it as a new heroine moving forward. In addition to the main chemical, there is at least two dozen synthetics. The one we are worried about, theres a couple now it was the big 13 or four times as strong not meant for human consumption. Its a large animal pain reliever. So if an elephant is a problem thats what you need. The dea and its reports will tell u us a list of the manufactured fentanyl is coming from china and north america, not the contaminated pills but for the heroine is through mexico and coming up through the cartel distribution. And where is it going . Places that have the most high fentanyl supply according to the National Forensics lab in the drug and seizure data and rates of opioid deaths down to appalachia and new england. The same states that have a higher heroine overdose death. One slide on one reason why we got here. Its promoted as pharmaceuticals they were quickly adopted because they worked and they did what people wanted them to do but they also became problem drugs so they are technologically advanced in terms of the hypodermic needle and has caused us to the first wave of the Opioid Epidemic in the United States. To misuse and abuse over the generations some of which have been cultural and related to news sources, so the vietnam era heroin epidemic is devastating. Its coming from southeast asia. The colombian heroine wave which people dont know about came when the colombian drug cartels brought an entirely new product, they brought heroine in 1992 to the problematic drug use in the United States. Now we have the opioid pill problem. Think about the extended release capsules that have high doses of powerful opioids but they are dissolvable and injectable. Its coming in now in the late 2000 blank. Talking about asking questions about it if mexico was producing a highly potent powdered hair when thats never been seen before and we dont know much about it. Its also coming in around 2013 a new source and Technological Advancement in that it is highly potent and it acts as a booster for heroine. Theres other consequences besides overdosing this Opioid Crisis injecting drugs Infectious Disease risk, bloodborne virus, hepatitis c and hiv and we should be mindful that the severe outbreak in indiana there are many scott county counties in the United States. We also have to be concerned about the bacterial infection. Because they love suffering and cost us a lot of money. All these things are preventab preventable. Part of my research is asked to talto talkwith users. These numbers hide the pain, experience and resilience and coping thats going on among the population. We meet with users in the street. We watched the watch them as the their drugs and inject. All the while fascinated by the new chemicals that come in new forms, colors, powders, forms of covers, new solutions. When i first saw this it freaked me out id never seen it before and ive been studying this for 17 years. If it is freaking me out imagine what the users are going through trying to adapt to this new thing thats out there. They want our help and its up to us to provide it. In summary, im proposing we start to separate them. Its not just one intertwined Opioid Epidemic that we need to treat heroine and fentanyl differently. It doesnt mean we are going to put the genie back in the bottle and its the only answer. This is a epidemic of crisis proportions and it is at its worst unfortunately but its also a crisis of economic opportunity. We turned the hiv epidemic around with a dramatic drop down. This is the effect of the appropriate government cultural social intervention treatment and prevention. It works it will work for the heroine and fentanyl epidemic as well. We shouldnt treated with the same anymore controlling prescription pill practices we can do. We need to treat heroine and fentanyl differently. We need to treat it as a poison epidemic. We are treating it as a drug epidemic and counting the dead bodies as they lie. We are not testing the drug accurately and informing the public accurately and we will talk more about that and the question and answer period. We need more in the treatment. We need more of this for the recovery acted as good a wonderful bipartisan response. It isnt going to be enough there is no way. We need faster responses to overdose. He needs to be not just in the hands of the paramedics and police that we need to give it to peers and it needs to be this generations at the epipen. It can bridge people as a treatment for aiding and abetting drug users in the political sphere. Thank you all for your kind attention. Carmack. [applause] that was a good introduction for next talk which will be coming from the government and im interested to hear how much the government is doing. Our speaker is the director of the Nation Institute which is one of the main institutes of health. Shes a true near and theology, the pharmacology of Substance Abuse and will tell us what those drugs are and what her office is doing. Good evening, everybody. Please be seated. Last time, we were discussing the issue of marijuana and how the change in policy will affect the function of marijuana. They were speaking about the worst crisis ever seen in the United States that relates to. Whats interesting about these which is very public. Number one, for small, the epidemics that we have in the past. This one basically came out of the healthcare system. It came out with good intentions which were need to treat those patients that are suffering from pain. Its particularly recognized that there was a concern that this was not properly treated for their pain. Since the late 90s, in the beginning of 2000s, it was decided that these would be the area of pain treatment and among the many for the joint Federation Commission of the hospitals and they recognized pain as a fifth vital sign into treated. Coupled with a strong apathy and the need to treat patients, at the same time they were. [inaudible] that resolved it in the prescription of what we avoid prescriptions. In the past there has been a lot of fear about the use of opioid for pain. They didnt want patients become addicted. That shifted radically in the 2000 with very strong advertisement from the pharmaceutical industry so that they would prescribe opioids. If you have pain you will not become addicts because of your pain medication. We came basically, confounded about what we have learned that we are faced, he knew these drugs were not addictive. Unfortunately, the numbers doctors are prescribing more and more opioids and that is not the case. As you look at the numbers forward, you want to look backwards. In 2009, 2003, one of the things they were showing me was the monitoring of the future. Monitoring the future is you know with teenagers. What struck my attention was in 2003 was the rate of use of prescription opioids like vicodin was 5 of teenagers. I have never ever seen and im not a psychiatrist but ive never seen so many teenagers taking in what we write. Then i looked at the numbers and we started to realize that there were some massive abuse of prescription through all the ages. Its almost like people were not listening to us and what were saying. We found a problem with the prescription opioid. They felt they were safe. At the same time there were reactions that you dont want to joke about the proper treatment of patients with pain. It wasnt until we started to see numbers like this one that the agencies realized, my god, we have a serious problem in our hands. These numbers are growing abruptly and rapidly. The overdose rates from the cdc and in 1999 they were pockets of the United States were very high overdose. In particular, you can see the different regions. Fourteen or 15 years over the United States has become affected. You can still see the main area in the appellation region. By the prior region you can see new mexico. Im waiting for the day because actually for starting to see further expansion into the northeast. [inaudible] so, why is it that opioid constrictions prescriptions and overdoses result in death . This is the peak. Underneath, there are multiple others things associated with opioid abuse. There are a wide variety of them they have psychological effects. The preceptors that are in our brain and all in our body and these receptors associated and this is something that showf corridors showing the highest levels and the full scale showing the lower levels where they are located in our brains. As you can see, there is a very high concentration and all of the regions of the brain that are engaged in our ability to perceive pain. That includes the. [inaudible] this is fundamental for our ability to perceive pain. So your receptors that are in an area that allows us to involve an emotional processing and if these fundamental for the negative reaction that we get with pain. That area is also loaded with opioid medication. When opioid medication binds to receptors it inhibits the preceptors of pain. This is the reason why opioid medication are the most effective medication that you can have for addressing severe, acute pain. It is almost immediate. The issue was that the acute, severe pain is something that you may, actually, may save your life through these drugs i have been in a car accident and i want them to, they would want to think because of the pain been so intense and it was extraordinary how the opioid i gave them healed it. The was gone and that sense of euphoria and relaxation was there. Thats exactly why these drugs are problematic. They are not just located in these pain sensors they are actually located in that area over there. These region is one of the most important region in professing pressure. When the receptors bind to the regions, they bind to the sensor and opioid medication can be one of the most rewarding and most addictive. We also have opioid receptors located in the brainstem which is the lower part of the brain in the back. Thats where we have many of the nuclear that is involved with these functions. One of these nuclei is associated with responsible for our breathing. When opioid medications bind to the sensors, they inhibit breathing and thats why you can actually ultimately died from an overdose because you stop breathing. This affects the reason why opioid medications are far from being ideal as treatment, not in one instance for pain, but the problem emerges when they use it for the management of chronic pain. According to the when you have pain that lasts for three months so what is the problem with opioid medication for chronic pain . There effective when you give it acutely. Your body will rapidly come tolerant to it which means that you need higher doses in order to achieve the same level of for the higher the dose you go, the higher the likelihood that you become addicted. So, the effects of the drug wile repeatedly, leads to conditioned response that leads you to crave that drug and it does that on all levels that can lead to addiction. Also, because the tolerance to the effect of opioid in the brain. [inaudible] the rate of the opioid reading sensor which accounts for why these medications are far from ideal for the treatment of chronic pain because you are going to need higher and higher doses and the higher the dose, the greater reason for addiction and the greater risk of overdosing from too much. As i pointed out, the epidemic started from our over prescription. Theres actually into a 13 Something Like 235 million prescriptions in the United States. Thats provides one month supply of opioid medication for every. [inaudible] in the United States. You say, maybe the United States , is also suffering from severe pain. If you look at the statistics, it is estimated that among elderly americans, 30 of them suffer from chronic pain. That in no way justifies this massive prescription. In fact, the United States actually prescribed between 80 and 85 of all opioid medication in the world. These leads us to prescribe that its overprescribing. This facilitated the reversal of this medication and it got to the black market and now its been abuse. We generated prescription addiction to opioids. People who were given medication for pain by the doctor become addicted and then those that actually started to experiment with his drug