Aaas. Im charles dunlap, interim director for the is center of science policy and society programs. Our lecture this afternoon on the Opioid Epidemic is the second in the 2017 aaas Dana Foundation lecture series on neuroscience and society. Our first lecture this year on the brain and videogames was held in march and our third lecture in september will be on meditation. So please keep an eye out for the announcement date. The Dana Foundation is a private Philanthropic Organization that supports programs like this one. For the last five years, aaas has partnered with the Dana Foundation to present an annual lecture series. By my count, this is the 20th letter in the series. Were grateful for the Dana Foundations support of this series and for deborah runkles leadership of the series in our scientific responsibility, human rights, and law program. With that, deborah . Thank you, charlie, and welcome. It seems to me there 7 a day goes by that i dont see a story in the news about the opioid crisis. As i was thinking about that today and leafing through the paper, sure enough, on the front section of the Washington Post is a story about how the governor and washington, d. C. s mayor are forming a combined database on prescriptions and who is getting these drugs. Its just another day. A few days ago, somebody sent me something that said that in an in a small town in kermit, West Virginia, a pharmacy received 92 million pills of opioid painkillers. 92 million seems a lot, doesnt it, for a town of 392 people . So theres really a very bad problem going on. And we are going to address it tonight, looking at it from several different points of view. And by the way, when were all done, i want you to know we do have a reception planned, so for the end of this. So tonight were going to look at an eagles eye view of the Opioid Epidemic, a more closein view from the National Institute of drug abuse, and then talk with Karen Drexler of the va about possible treatments. Our first speakerer is dan ciccarone, a professor of medicine from california, san francisco, who specializes in Community Medicine and treating diseases in poverty. He was a leader in the hiv aids epidemic in the early days. Hes going to talk to us tonight, as i said, an eaglei view of the scope of the problem. Dan . Thank you, deborah. Is there a direction to get the next slide up . The screen is up but not there it is. Oh, there we go. So im a typical academic and i cant even begin to talk until my slides are up, you know, im little lost without them. Hi, everyone. Dan ciccarone, ucsf. Yes, im a Family Community doc, so my perspective is one of trying to see ways to improve community health. I started with the hiv epidemic but found my way to the drug epidemic a few years ago. Im here tonight to talk about prescription pills, heroin and fentanyl. Did the wrong thing again. Lets try it again. Voila. So i want to go through some epidemiological data on the opioid overdose epidemics, comparing prescription pills with heroin, looking at some demographics and epidemic curves. Ill also spend a little bit of time talking about the illicitly manufactured fentanyls, one slide on etiology and one slide on other consequences. Yes, got it. Most of what im presenting is publicly available data, cdc and the dea, for example. A little bit is going to come from my study, heroin in transition study funded by the National Institutes of health, National Institute of drug abuse. For the First Time Since 1993, the u. S. Death rate has gone up year to year. 1993 was the handwriting of the hiv aids epidemic. And here we have the ten leading causes of death as of 2015. Heart disease and cancer are the two big elephants in the room, sort of cancel each other out, one went up, one went down. If we go to number four, unintentional injuries, we see a clear bump up, 2014 to 2015. We were shocked in 2011 to find out that two of the leading causes of Unintentional Injury death had crossed over, with drug poisonings on the rise and Motor Vehicle accidents on the decline. Of course this is good news for Motor Vehicle accidents but bad news in terms of the drug epidemic. This is a graphic from the new york times, i was working with josh katz on this. Drug poisoning overdoses, number of deaths have now exceeded car accidents, gun violence, and even hiv. You can barely see the hiv line there, i apologize. Its a steep rise up. Its peaking around 1993 and then a decline. Weve moved from epidemic, drug poisoning or Opioid Epidemic, to a crisis. Looking at hospitalization data, this is the curve for the overdose epidemic. Dramatic rise up, 1993 to about 2011. Some good news, plateauing, perhaps even a decline post2011. This of course is based on the work were doing to restrict excessive prescribing practices. Unfortunately this is now heroin overdose hospital admissions, dramatic increase up since 2008. Its not necessarily the magnitude in this slide with that sleep curve that has me concerned. Year over year, no end in sight. Whats fueling heroinrelated overdose . Three possibilities. One is theres evidence that the number of heroin users, the denominator, is rising. And theyre coming from two paths. One group is coming from opioid pill dependency, finding heroin is more available and cheaper and replacing their high level of pill dependency with a heroin dependency. Heroin is cheap, its pure, its good, and it is everywhere. The supply has changed dramatically in the last few years. Places like burlington, vermont, are not supposed to have good heroin, and they do. My group has several stories, intertwined epidemics, we used that term as early as 2012. One group of opioid users could transition back and forth. Thats because the opioids are treated equally in the body. We also wrote a story about folks who are on heroin and they transition. With the new users and young users telling stories about how they started with pills and then moved over to heroin. This is a picture i took in an alleyway in philadelphia just to sort of symbolize the pill to heroin intertwining. And heres some data from my group looking at comparing the demographics by age for these epidemics. Here is the pill overdose problem. Predominantly, 20122014 data, this is an older age group, whereas for heroin, a younger age group. We show a rising problem among young people, there we have it. But if we shift this over, we see some evidence of the intertwined or transitioning between opioid pills and heroin. As the opiate overdose year to year rate goes down, you can see from the blue to the green, we see that heroin overdose is going up in that same age bracket, 2012 to 2014. By geographic region we see a starker difference. Opioid overdose is relatively even across the country. We like to think its worse in places like appalachia, but to our eye they look more or less even by region. That is not true for heroin. Heroin is dramatically different. The northeast has had a problem for generations with an endemic issue with heroin. The midwest, the red line, which is now highlighted with the gold arrow, going from low levels of heroin overdose to very high levels of heroin overdose. Clear geographic disparity that cannot be explained by a simple opioid pill to heroin transition among the population at risk. So in addition to that story, we have to tell another story, that heroin is itself becoming a more dangerous drug. It is being adulterated, contaminated with synthetics such as fentanyl, and its coming in a new form, which has received very little press. Lets talk about fentanyl. Fentanyl is integrated into the heroin supply. You dont go to a separate corner down the street and ask for some funny street name for this new drug called fentanyl, right . You go and by heroin, and the heroin you get, if youre in that right region, the right mill town in massachusetts, for example, youre going to get fentanyl contaminated heroin, a potent synthetic opioid, 100 times more powerful than morphine by weight. Its appearance, weve had multiple appearances in the past, but the latest appearance has been a long one, longer than the other waves, began in late 2013. Its illicitly manufactured pharmaceutical. Its analogous with what we saw with an adult raeadulterant, it ubiquitous in the cocaine supply. This implies there may be a future for the heroin plus fentanyl as the new heroin moving forward. In addition to the main chemical which is fentanyl, there is at least two dozen analogs. And in addition theres other novel synthetics like 4700. Carfentan carfentanil, the big bad boy were worried about, carfentanil is the big one. A thousand x morphine, three to 400 times as strong as heroin. This is not meant for human consumption, its a large animal pain reliever. So if your elephant has a problem. The illicitly manufactured fentanyls are coming from china, through multiple routes in north america. The predominant route for heroin is through mexico and coming up through cartel distribution. Where is it going . These bottom seven states are places that have both high fentanyl supply, according to the National Forensics lab, and high rates of opioid deaths,app england, the same as for heroin deaths. One reason why we got here, its called supply side theory. When morphine and heroin were synthesized and promoted as pharmaceuticals, they were quickly adopted because they worked. They did what people wanted them to do. But they also became problem drugs. So we have novel drugs, Technology Advancement in terms of synthesis and Technological Advancement in terms of the invention of the hypodermic needle. Weve had waves of heroin, use, misuse, and abuse over the generations. Some of which have been cultural. Some of which have been related to new sources. So the vietnam era heroin epidemic, devastating u. S. Cities. That was a new source of heroin, type 4 heroin coming from Southeast Asia. The colombian wave came when colombian drug cartels brought in heroin in 1992, which led to a wave of problematic drug use in the United States. Now we have the opioid pill problem. Again, i iatrogenic, a novel form, high doses of powerful opiates. Theyre easily abusable, crushable, dissolvable, injectable. Heroin is coming in now, early 2000s. I havent spent a lot of time talking about it, but mexico is producing a highly potent powdered heroin that hasnt been seen before. Synthetics are also coming in, a new source and a Technological Advancement in that its highly potent. Ill remind everyone there are other consequences besides overdose in this opioid crisis, injecting drugs leads to Infectious Disease risk. Blood borne viruses, hepatitis c and hiv. We should be mindful of the scott county the severe hiv outbreak in scott county, indiana. There are many scottcountylike counties in the United States. We also have to be concerned about bacterial infections, soft tissue infections, that cause a lot of suffering. It costs us a lot of money in terms of treatment. All of these things are preventible. These numbers hide the pain, the experience, the resilience, the coping thats going on among the user population. We meet with users in the street. We watch them as they prepare their drugs and inject, all the while fascinated by new chemicals out there, they come in new forms, new colors of powders, new colors of powders. Solutions, this bright yellow solution freaked me out, and ive been studying this for years. If its freaking me out as a Public Health researcher, you can imagine what users are going throu through. They want our help and its up to us to provide it. We need to treat heroin and fentanyl differently than were treating the prescription pill problem. Supply shocks can lead to epidemics. Unfortunately that does not mean were going to put the genie back in the bottle or that supply is the only answer. Yes, this is a crisis of epidemic an epidemic of crisis proportions as were besting the hiv epidemic at its worst, unfortunately. Its also a crisis of opportunity. We turned that hiv epidemic around. Look at that dramatic drop down. This is the effect of appropriate government cultural social intervention treatment and prevention. Treatment and prevention worked for the hiv epidemic. Treatment and prevention will work for the heroin and fentanyl epidemic as well. We should not treat these epidemics the same anymore. Controlling prescription pill practices, prescribing practices we can do, a lot of effort out there, it can work. We need better surveillance. Hint, we need to treat this as a poisoning epidemic. Were counting the dead bodies as they lie. Were not testing. We need more evidencebased treatment. Methadone and back up ouponorph. We will need faster responses to overdose. Naloxone needs to be in the hands of paramedics. Its in the police tool bet, great, fantastic. We need to get it to peers, to users, to families. It needs to be this generations epipen. Its Cost Effective and can bridge people into treatment. We tend to think of Harm Reduction as aiding and abetting drug abusers, in the political sphere. Harm reduction saves lives and can be a bridge to Clinical Care and to treatment for the affected individuals. And Public Safety and Public Health collaborations, sort of the new mantra, this can happen. Okay, we need to work with the criminal justice side of things and Public Health side of things, stop treating drugs as the sort of the special privilege of the criminal justice folks and the injured bodies as only Public Health. Both sides need to work together. And with that, ill end. I particularly want to acknowledge a statistician on this project at the university of maryland. [ applause ] that was a good intro for our next talk which will be coming from the government. Im anxious for you to hear how much the government is doing. Our speaker is nora volkow, the director of National Institute on drug abuse which is one of the national insults of health. She has been a true pioneer in the study of the physiology, the pharmacology of drugs of abuse. And she will tell us a bit about what those drugs are and what her office is doing. Good evening, everybody. Its a pleasure to be here. I think that ive been here several times. Last time it was actually, we were discussing the issue of marijuana and how all of the changes of policies was going to affect the potential negative effects. Today were speaking about the worst crisis weve ever seen in the United States that relates to withdrawal. What is interesting about this crisis which actually is very, very tragic, is number one, first of all, different from any other epidemic that we have had in the past. This one basically came out of the Health Care System. And it came out of very good intentions, where were we need to treat those patients that are suffering from pain. And this was the severe state. It was recognized there was a concern that patients were not being treated properly for their pain. In the late 90s, in the beginning of 2000, it was decided that these would be the area of pain treatment. And among the many actions that took place was the joint Accreditation Commission which actually credits hospitals, demanded that we recognize pain as a vital sign and that we treat it. This was coupled with a strong emphasis on the need to treat patients at the same time there were limited interventions that can be used for pain. And that of course resulted in the massive expansion in the prescription of opioids medications. In the past there has been a lot of fear about use of opioids for treatment of pain because of fear that patients will become addicted. That shifted dramatically at the beginning of 2000, and with very strong advertisement from the pharmaceutical industry to encourage physicians to prescribe opioids. We were taught in medical school, and this was taught until very recently, if you have pain, youre not going to be using pain medications. We as physicians became basically confounded about what we have learned in the past it could produce addiction and now we were faced that we needed to treat them, that these drugs were not being addictive. Unfortunately the numbers as physicians start to prescribe more and more opioids, it became clear that that was not the case. And as you look at the numbers backwards, its always easier to look at things backwards. I came in 2003, one of the first things they were showing me was results of monitoring the future. Monitoring the future is a survey we do with teenagers. What struck my attention immediately in 2003 is that the rate of use of prescription opioid was 10. 5 among teenagers. And i have never, ever seen, and im a psychiatrist, in my life a teenager taking an opioid. And thats what caught my attention. And when we started to look at the numbers, we started to realize that there was a massive abuse of prescription opioids across all ages. But it was almost like people were not listening to us, what we were saying, i have a problem with prescription opioids, because there was a sense that they were safe, and there was at the same time immediate counterreaction that you dont want to jeopardize the proper treatment of patients with pain. And it was not until we started to see numbers like this one that then the agencies realize, my god, we have a serious problem in our hands i dont think anything speaks better, when you start to see numbers like these that grow so rapidly. The overdose death rates from the cdc, you can see 1999, there were some pockets of the United States with very high overdose rates. In particular you can see the appalachian region. And over 14, 15 years, the whole United States appeared to become infected. You still see the main areas for overdoses in the appalachian region. As with the prior speaker, we see areas in new mexico that in the past had not seen it. And now im actually waiting for the data on 2015, because i actually were starting to see further expansion into the northeast. Now its driven by the emergence not just of pure heroin but also fentanyl and fentanyl synthetic opioids. This is the tip, because underneath it of course there were multiple adverse conditions associated with the use of prescription opioids. Opioid medications actually, there are a wide variety of them, but they all have a common pharmacological effect. They basically arine ing agonis. The opioid receptors are actually associated, and this is an image that shows using positi tomography, showing the high levels, the cold scale showing the lower levels, where they are located in our brains. As you can see that there is a very high concentration in all of the regions of the brain that are engaged in our ability to perceive pain, what we call the pain network. And that includes the acc. The central area in the brain. And thats fundamental to our ability to perceive pain. There are receptors in the area which is involved in emotional processing. It is fundamental for the emotional negative reaction that we get with pain. And that area is also loaded with opioid medications. When opioid medications inhibit the perception of pain, this is the reason why opioid medications are probably the most effective medications that you can have for addressing severe or acute pain. They act almost immediately. The issue was that acute pain is something that you may one of these drugs may save your life. I dont know if any one of you has been given them. I have been in a car accident and i wanted to actually go unconscious, i wanted to faint because the pain was so intense. Then they gave me an opioid and it was an extraordinary sensation of wellbeing. A great sense of euphoria and relaxation. And this region is one of the most important massive prescriptions. In a fact the United States prescribed between 80 and 85 of all opioid medications in the world. So we were overprescribing, the black market, and started to be abused and that then led to addiction. People that were given these medications, morphine, told by the doctor that they will not be addicted, become addicted. Then those who started to experiment with these drugs. And these two actually ultimately generated a similar syndrome of addiction, control over drug safety and the escalation of drug intake. So there was a massive amount of training physicians to improper prescriptions of opioid medications. When it came in too fast, it was not associated with training on how to use these drugs. So physicians were starting to prescribe with no knowledge. So now we knew, for example, that there are certain prescriptions practices for opioids that are particularly risky for overdose. When you give more than 80 morphine equivalence, when you mix these medications with be o benzodiazepine or alcohol. We still continue to do these type of prescriptions, physicians are prescribing them without considering the risk of overdoses. Overall were seeing changes in the right direction, 15 decreases in the amount of opioids being prescribed. Between 2010 and 2015. This is not a major change, but its still in the right direction. Unfortunately, this does not in any way change the overdose rates that have continued to escalate, very much in line with what youve heard in the prior presentation. You have 30,000 people die last year from an opioid overdose. When you see the commonly prescribed opioids, they are not going down. What is going up is that line of heroin and other synthetic opioids. Synthetic opioids, heroin is actually the result of as we look at in terms of what is driving these very high rates of overdoses. For many, many years in the United States, we have very, very stable, low levels of abuse of heroin in this country. And the rate of death was basically you look at it, so constant, 2000, people dying every year from heroin. And then the amount of heroin, you start to go up. It wasnt dramatic, not dramatic, its actually around 700, 800,000, coming from 500,000. The number of people has basically quadrupled. What is driving this . Were driving it, we have a much purer heroin thats accounting for the very high rate of overdose. And its a different population. Were seeing areas more affected than most. So in the meantime, were seeing that this heroin is being laced with fentanyl. Thats whats driving the massive amount of Overdose Deaths. Of those new heroin abusers, 80 of them started abusing prescription opioids. If you analyze really what happened and how the heroin was deployed coming from mexico, all the heroin in the United States is from mexico, actually it started in states where it actually has the largest problems with prescription opioids. Those individuals that did prescription abuse. There is it important to address because what you dont want to communicate is that we want to actually contain the heroin epidemic, we should make prescription opioids more available wlachlt is leading people to change is that theyre very far to get it. Thats actually exactly the incorrect answer. In order to address it, we very to prevent abuse and addiction to prescription opioids. Because it would prevent those individuals are not going to transition to heroin. These are the numbers you saw in terms of how when a drug becomes, we know that for any drug that is out there that the price plays an important role. So were getting heroin from mexico that is actually coming with an extremely high purity and increasing the price dramatically. The price of heroin in the United States has been going down. In the meantime, were seeing the drugs are easy to synthesize. Its so potent or some of them are that you can actually bring it in very small volumes from the supply perspective, this poses a tremendous amount of challenge. Youre not carrying big volumes. You can carry this very small amount of drug that come an pro a multiplicity of dosages. It is actually poses tremendous challenges from the Public Health consequences associated with the overdose, the very, very high risk of overdosing with these drugs. So what is it that the nih is doing to address this problem of the epidemic . Our perspective is what we have the hiv epidemic, where we have the ebola epidemic, we address it using scientific solutions. They can provide the means to actually control this problem. Its not any different for opioid crisis. The way we review it is we need to understand the root cause of the problem. That we have a problem with patients suffering from pain for which we dont have many alternatives n particul alternatives. In particular the manage ment is for chronic pain. In the United States approximately 100 Million People suffer from pain mod troerate t severe. We need to develop better treatments and safer for the management of chronic pain. The other is we need to do interventions that can actually prevent the overdoses. We have other drugs. But we need to actually go and design alternative strategies that can hept individuals thlp that are reverting from an overdose otherwise theyre going to overdose again. Finally, we need more treatments for opioid disorders. We have bupronorphine. It is useful but it is not sufficient and ill show you why. 100 Million People are suffering from pain and yet we dont have many medications. And for many, many years pharmaceuticals have actually poured millions of dollars into develop an opioid medication that would not be addictive. And this was this resulted in serious results. And so many what manufacture the pharmaceuticals kept doing is actually disenfranchise themselves from the pain from the development of pain medications. Now science has now recently with the ability to actually identify the three dimensional structure of the opioid receptors, been able to identify that receptors actually take various pathways. Two of them pear to be particularly relevant. The classical, that is necessary for anagesia. So the g protein is the one associated with analgesia and side effects. What pharmaceuticals are doing is developing medication thats do not engage the beta resting pathway with the notion that this medications will be useful for pain manage mement without producing overdoseors addiction. And research is underway and face technical trials and have actually are being done in one of those compounds. For overdoses, we work what is the issue completely to save them. The more widely available the drugs, are the greater the likelihood of success. But now with phentonil, were learning kit not reverse the patients and they need higher doses. Its almost impossible to actually resuscitate them because they die actually as they are injecting the drug. The phenotnil and the drugs get together brain so rapidly. They overdose again and eventually die. We have to treat them so we can protect them from future overdoses. Finally, medication. We have multiple treatment medications. Each of them different characteristics. Methadone, bupronophrine and dpen depending on what characteristics, can you use one medication or the other. They prevent overdoses and relapses and Infectious Diseases but theyre not being used. And less than 15 of individuals in the United States that could benefit from a medication are getting it. Multiple reasons why that is the case including stigma but also lack of infrastructure. So weve been working with the system in order to engage physician o physicians on the proper treatment of the opioid addictions. Developing medications, alternative medications that will be in compliance with a partnership that we did with the fa pharmaceutical that results Administration Every six months which would facilitate the compliance of the patients that are addicted to this opioid medications. And finally, with science, of course, we look at transformation. So an area were exploring for heroin and also now for fentanyl is the develop ment of vaccines. Vaccines just using the same strategy we use for other vaccines that will develop antibodies from the drugs to when the person takes the drugsz, the antibodys interfere with it and interfere with it going into the brain. This will be useful for preventing overdoses and, of course, for treating those that are addicted and perhaps into the future for prevention. And with that, twini want to advertise some of the document thats we get if youre interested on any information regarding our research programs. And again, i want to thank you for your attention. Nil. There is not a cheerful topic. Im hoping our next speaker gives us a little cause to walk out of here with a little bit of hope. Our speaker is Karen Drexler. She is the National Mental Health Program director for addictive disorders and Veterans Administration. And who should know more about misuse of drugs than the Veterans Administration . Dr. Drexler is certified in both psychiatry and in addiction medicine and she is going to talk to us about treatments. Thank you so much. Im very honored to be here. Thank you to aaas and the Data Foundation for this invitation. And im delighted to give you a third perspective tonight. I am as debra said an addiction psychiatrist. I still practice at the Atlanta Va Medical Center where i practiced for most of the last 25 years. And i also for the last three years, though, have been working for Va Central Office here in washington, d. C. Doing Addiction Treatment policy and having the opportunity to be a consumer of science on two levels. Both as an individual practitioner but also as someone trying to translate the science to improve the health care of a population. So im employed full time by the department of Veterans Affairs and i have no commercial financial conflicts of interest. And tonight what id like to do is talk about i dont have to talk about opioid use disorder because the doctor has done such ater irving job of that. And ill mention as the doctor also spoke about how opioid use Disorder Treatment really begins with prevention and how we used the science to inform our policies about that. And then also how effective opioid use Disorder Treatment from i think a little bit more of the art of medicine. We apply with the science has shown us in a way thats patient centered and collaborative when were working at our best. I want to use this example. This is a veteran. This could be any one of us. Shes a very hardworking, licensed professional nurse. Practical nurse. Who was referred for Substance Use Disorder Treatment after an overdose. This is the culmination of 30 years of experience with prescription opioids and other controlled substances. She injured her back at age 24 and treated briefly with opioid Pain Medicine. She had a series of reinjuries and surgeries and ultimately ended up being treated with both o o opioids and muscle relaxants and multiple providers as her tolerance increased, her drug hunger became greater and even by shopping for multiple providers, it was not enough. She ended up buying some pills on the street and ended up with an overdose. Now for her, i shared the criteria for prescription opioid abuse disorder f a person is taking them as prescribed, we dont include the increasing tolerance or the withdrawal symptoms as criteria for making a disorder diagnosis. But she really had most of these symptoms. She had craving or strong desire to use opioids. She was using in situations when it was hazardous, when she was really too intoxicated to drive. She was using larger amounts than she intended. And she had difficulty cutting down. She was spending a lot of time figuring out how to get the next opioids and knew that opioids were causing major problems. After the overdose, her primary care provider said i will not prescribe opioids for you unless you go to the Substance Abuse treatment program. And thats why she saw me. I was the gatekeeper for her next prescription of opioids she was hoping to obtain. So as both previous speakers have talked about, since the 1990s, opioid pain prescriptions have increased. But we really have not seen any change in americans reports of pain. However, the Overdose Deaths have increased dramatically. And as have the number of people who have developed opioid use disorder. Thou those intertwining epidemics. And this just my slide. Those of who you are epidemiologists in the audience may recognize this is a map of london in the 1800s. Showing cases of cholera that dr. John snow traced to the broad street water pump. And the solution was to take the handle off the pump. And had a tremendous effect on the cholera epidemic. I think this slide that weve already seen some versions of this where the kilograms of opioids sold went up, so did the deaths of opioid overdose and the opioid use disorder. There is our map of london for the Opioid Epidemic. And one important intervention as has already been discussed is to take the handle off the pump and to reduce the number of prescriptions for opioid Pain Medicines. So the centers for Disease Control and prevention has developed an Evidence Based guideline in which they recognize that nonopioid therapy is preferred for chronic pain for the reasons that the doctors mentioned. When using opioids to use the lowest effective dose for the shortest period of time and to exercise caution and monitor closely. In the department of Veterans Affairs, we partner with the department of defense to create our own clinical practice guidelines. We have them for many medical conditions. And we use as the cdc did the grade methodology which takes into account four domains including the balance of desirable and undesirable outcomes and our confidence in the quality of the evidence as well as other factors. We use this evidence hierarchy that may be familiar to manufacture nut audience. Whereas earlier guidelines were often based on Expert Opinion for these guidelines we looked to at least observational studies that show some control element. And best of all randomized controlled Clinical Trials are even better analysis in multiple Clinical Trials. Based on these we came up with 18 Evidence Based recommendations to our practitioners. Im highlighting four of them here. We recommend alternatives to opioid therapy such as self manage ment strategies, exercise, other nonpharmacy treatment ands when theyre used, nonopioids, nonsteroidal drugs and eye bu pro fen a for g the long term therapy, online misbeing litigation. Such as dprrug monitoring progrs to make sure that were not double prescribing. And monitor for potential and suicide alt and providing overdose education to our patients prescribing other drugs and making it as widely available as possible and assessing for suicide risk and intervene wlg necessary. Finally, as did the cdc, we recommend monitoring patient whos have chronic pain for the develop ment of opioid use disorder and whether we find it providing medication assisted treatment. So in va, in order to take the handle off the pump, we have been reducing opioid prescribing through our opioid safety initiative. This has been an education for providers as well as some metrics for Quality Improvement that we have disseminated throughout our system. We have seen some improvements. A 33 reduction since 2012 in opioids over time. It has been reduce bid 39 . And the veterans on long term and the drug streen in the last year has increased to 87 . We are communicating with Prescription Drug Monitoring Programs in all but five of the states which is a tremendous technical feat because not every state Prescription Drug Monitoring Program uses the same software and they dont necessarily communicate with each other or with us. But i have to give credit to my colleagues in pharmacy benefits management and in i. T. Fo ovr overcoming many hurdles. I wont go into detail about these slides. The va is not alone. Nationally weve been making progress and yet Overdose Deaths have continued. This is a complicated picture that the doctor helped discern for us of intertwined epidemics. As was also pointed out, patients prescribes opioids long term are at risk for developing heroin addiction. So lets get back to my patient, the nurse. When her physical told her no more prescriptions, she turned to the elicit market and when she came to me for treatment, i talked with her about other drugs. Now i explained to her the mechanism of action and took this approach which were advocating system wide that patiented treatment for opioid abuse disorder should be patient centered and Evidence Based. It should be Life Sustaining and empowering the patient to be a partner in their care. And it also needs to be accessible to those who need i had. So for patients centered care, it begins with shared decision making. The patient is the expert on his or her life. Hopefully we clinicians are experts on the entire menu of Treatment Options and we provide that information in a way thats easy to understand. And my colleagues in the va and our academic detailing service have created some education materials that make it easy to convey the rational for medical assisted treatment. Opioid therapy is a particular kind that includes both bupronorphrine and it reduces hiv risky behave yoshgs criminal behavior, cravings and withdrawal and importantly opioid use. And as they also showed, there are two kinds, methadone is a full ago onnist and then bupronorphine makes it safer to prescribe in any setting. Methadone becausest full agonist is only limitedly available. So im able to provide this information. Buprenorphine is more readily available. You dont have to pick it up every day and take it in the clinic. It is fda approved. It improves treatment retension. It reduces mortality and it is recommended for most patients except those who have an anticipated need for opioid Pain Medicine. So i talked with my patient about how some patients find that actually getting on buprenorphine helps improve the pain. We also discussed one other option which is the extended release injectable which will block the new receptors and any oep identifies for pain and she elected not take that one. So i wanted to also mention that its not just the medication alone but also medical manage ment. This is what we called it in our clinical practice guidelines. There are several Research Studies showing this approach that relatively brief counseling but close monitoring by the clinician including drug testing, asking the patient about their use, asking about consequences and potentially using a measure ment based tool like the brief addiction monitor. Educating the patient about the opioid use disorder consequences and treatments connecting the dots, if you will, and encouraging them to abstain to attend mutual help groups in the community and to make important lifestyle changes. Now my particular patient was also taen also attending at a lot of groups and classes and she was learning different skills to support her and elected to take buprenorphine. Because of her pain, her chronic pain, i suggested she split the dose and take it twice a day rather than once a day. And she kpleecompleted our inte outpatient program. But really within a week of starting this medication, she was so engaged and learning so much. She started exercise. She started being active in 12 Step Recovery groups. And then i transferred her to a continuing care group because of our system i work in the intensive phase. So she had graduated and moved on to a less intensive phase. But she kept coming back at every opportunity stopping by my office and saying, dr. Drexler, that was the best medication i cant tell you. And telling me about another person that she knew back when and that she saw and encouraged to come and find treatment. It really turned her life around. And she remained in recovery on medication for years. She moved on and she keeps dropping in every once in a while to let me know how shes doing. So i want to raise this issue that dr. Volkov raised. Our treatment for Substance Use disorders is episodic, as if we were treating a case of pneumonia. And once we finish a 28day in patient program, we would be cured forrest of our lives. But these are really more chronic illnesses that would benefit most from the long view, from a chronic disease manage memanag management model. So this is something that were taking the synthesis of the evidence and suggesting this model moving forward. This is really a work in progress. We havent implemented it yet. But were promoting self manage ment. We have good evidence that participating in group mutual help like narcotics anonymous or alcoholic as none mus is helpful. Teaching coping skills that folks can use to cope with pain or to help to get to sleep without using medications. And then disseminating out the Evidence Based treatment into General Health care settings wherever the patients are presenting and primary care and Pain Medicine in, hepatitis clinics and then also keeping infrastructure for managing those most complex patients. Now this slide apologize. I know you probably cant see the graph. What id like to point out on the graph is that the medication assisted treatment with buprenorphine and methadone both reduced mortality for those with opioid use disorder and its not just overdose mortality. Its all cause mortality. So what are our challenges and next steps of getting this life saving treatment to those who need it . Among the doctor eluded to this earlier, among privately insured patients hospitalized for opioid abuse disorder, only 17 received medication following their hospitalization. Can you imagine if we treated diabetes the same way . 54 received some Psycho Social Services following hospitalization. But 40 received no continuing care. According to others, in 2013, 27 of treatment plans for heroin use disorder in sud specialty clinics included medication assisted treatment. We have a long way to go. And patients in the va center, 34 received medication in fiscal year 2016. So we can anticipate that demand for opioid use Disorder Treatment is going to continue to increase. And our next steps are challenging on how to disseminate the Evidence Based practices widely so theyre available. So as i mentioned the good news is we have even as demand has been increasing, some of the efforts weve made to educate providers and to support them with consultation and education have increased our proscribing. And then id like to just present to you four Evidence Based models that we might follow. One is brief counseling is sufficient for many patients with opioid use disorder. They rand omized patients in primary care to receive physician management, this brief counseling that i mentioned before. Either once a week tapering to monthly for stable patients or receive that with an additional hour of counseling. All of the patients received buprenorphine. They had some Pretty Amazing results. Almost 80 retension in treatment at 12 weeks. And four to five weeks of continuous consecutive abstinence but that additional hour of Cognitive Behavioral Therapy really didnt make a difference as long as the medication was prescribed with close monitoring and that brief counseling by the prescriber. So i think thats an opportunity to disseminate this more widely. This is from a Clinical Trials network. It was a very similar model to general Mental Health care settles. While they were on the buprenorphine, their chances of remaining sober were ten times greater than after it was tapered off at the end of the trial. And this is the socalled massachusetts model of nurse Care Management by dan alfred, colleen mabell and other colleagues in this ch theyve taken the model and instead of the physician or the prescriber doing the brief counseling, trained nurse care managers to do the brief counseling and the close followup. And they work within a team with a clinical pharmacist and counsellor as well. And they have been able through that model to dramatically increase the number of patients receiving buprenorphine. And then another similar but different model in the state of new mexico as you saw was heavy hit early on in the opioid crisis, the state of new mexico realized they needed to disseminate medication assisted treatment out to rural areas quickly and they developed a model using a telehealth hub in which providers and primary care clinics in rural new mexico had a weekly meeting basically clinical rounds like you might have done in medical school and residency only done virtually using telehealth and consultation and training, they were able to dramatically increase the availability of medication assisted treatment. And then finally ill mention this one model thats from the alcohol literature. This is dave oslin and colleagues in the va who randomized patients to receive alcohol care manage ment. Again with care managers supporting the primary care docs. As the primary care docs prescribe naltrexone and they found those who were randomized to receive that care and primary care not only were they better engaged in treatment because they didnt have to pass from one clinic to another, but the percent of heavy drinking days also was superior to those who got treatment as usual. So im very hopeful that well be able to disseminate these models out and one key partner at least for us in the va is academic detailing. We use the same techniques that pharmaceutical Companies Use to promote new products to promote Evidence Based best practices. And this they helped partner with our overdose education distribution. And this is just a graph that since 2014 when we started this we have actually dispensed over 71,000 at this point its over 75,000 rescue kits. So potential next steps. I think there is a lot to be done in terms of implementation science. We have some actual treatment thats work pretty well. That are well established by the science but getting them out to the patients who need them is the next challenge. There are also new exciting even better medications on the horizon that dr. Volkov talked with us about. And how we can enhance education. Right now in order to be able to prescribe buprenorphine, physicians have to take an eight hour training course. Nurse practitioners and pas have to take 24 hours of training. That seems like a burden for someone with a busy clinical practice. But why is anyone graduating from medical school or Nurse Practitioner or pa School Without having that eight or 24 hours of training in their basic curriculum . So thats one area where we could improve. We could also let folks in the field try these models. Learn from those and use the lessons learned. So opioid abuse is treatable and p preventable and we do need more help for newer, better treatments as well as how to implement the ones we have. Thank you. Dan and nora, would you come up . Were going to take questions from the audience. But you need to line up there. There are microphones in the two aisles. When i call on you, please give your name and affiliation status. I wanted to ask a question of let me start with karen. Karen, is there a difference between the veteran population and the nonveteran population . Men and women of the same agegroup . N. Terms of their rate of taking drugs or using opioids . But stick with opioids . Okay. So there is an increased risk for chronic pain among the veterans. And i dont know off the top of my head about whether we prescribe opioids more for patients would have chronic pain in the general population. Does it make sense that veterans have more krotic pain. Theyve had very physically demanding jobs. Very demanding. Jumping out of airplanes. My son did that. Doctor, why is it that some people can have, for example, break a bone and dont have surgery and be prescribed an opioid and take it for a period of time and some people become addicted and other people just quit taking it . Well, were all built differently. One thing we come to recognize not just for oep identifies but for any drug is that there are some people that are more vulnerable to become dakted than others. So what, of course, physicians always want to know is can you give me a test that can let me know if someone if im going to prescribe them on opioid are they going to be at higher risk or not . We know that a lot of that is genetic. We dont have a genetic test right now that can help us. But there are many things that we can actually ask patient thats can give us an idea of their risk. One of them, have they been dakted in tdak dakted addicted in the bast to drugs . That should alert physician thats theyre at high risk. Also age. The younger you are, the greater the risk you may have of becoming addicted. This is one of the reasons in general medications should not be prescribed to teenagers unless they are necessary. And so and, too, Family History also is a factor that contributes to that. Mental illnesses can increase your risk for becoming addicted to drugs. Theyre actually many things that can make you feel better and that leads you to actually seek them out in order to also medicate themselves. But at the end of the day, there is no test that can guarantee that you a patient is not going become addicted. There are factors that tell you someone is at greater risk f someone is going to be prescribing opioids repeatedly just as its described in the cdc guidelines, these require they be monitored very, very carefully. That every time that a prescription is going to be renewed that the physician evaluate to make sure that there is not any development of misunite of opioids or addiction. Thank you. Dan . Yes . I wanted to refer to your graph that showed the heroin users on the left side, the younger users. Are they just switching over . Are they just people who are switching from they would have been cocaine addicts or Something Else years ago but now heroin is the in drug or its less expensive or Something Like that . Or are these attracted new temperature that would not have been addicted to another a substance. Just like the previous question. The saeanswer is complex. Epidemics can have a sort of wave effect that just sweeps in people and increases the size of the vulnerable population, retested the size of the vulnerable population by excessively prescribing opioid pills. What i would like to answer your question sw an anecdote. An anecdote, sorry. And that is in my observations my team and i have been to little towns out side of boston, lawrence, baltimore, chicago, West Virginia, we see a lot of new people out there. And new people arent necessarily coming from prescription pills anymore. Theres a new wave that are coming in there. Theyre young. And im not sure whether they would have done another drug if heroin wasnt the thing now. But i do know that there is a mixed picture right now. There is a cultural wave, another an anecdote, for example, i met a 29yearold out side of a small town in West Virginia, nice guy. Works and just also happens to have a daily heroin habit. And he went back to his ten Year High School reunion, sml town. Everyone knows everyones business. Everyone knows who left, who stayed, who lived, who died . Half half his High School Class is gone. The first time in 17 years i almost had to stop an interview because i had a very motional response to that. Pills and alcohol pills and heroin. One or two motorcycle or industrial accidents but mostly pills and heroin. There is something very large out there hang right now. There is no easy answer to. Yeah. Okay. Lets take some questions. Go ahead. Thank you. My name is ashby sharp, chief of ethics policy. I just want to add a dimension to the doctors excellent presentation that one of the things that we did in our policy on long term opioid use was to p prohibit the use of pain contracts because from an ethics perspective, we felt they were unenforceable and instead we substituted a robust and informed consent process. So that patients get education and a good conversation about the risks, benefits and alternatives to long term opioid use. But the two questions i have are actually bin actually about intergrating policy strategies. So Patient Satisfaction surveys, ive heard from clinical providers outside of va that they feel pressured to prescribe all drugs but in particular opioids in order for patients to give them a positive satisfaction rating because theyre going to be judged on that. And the seconds was what about Third Party Insurance coverage for opioid use treatment and what can be done to encourage other players in the market to get on to this initiative. Dr. Drexler, do you want to take that . Ill take the first one. Im not an expert in third party care. I dont think any of you are probably. Having been in the va. But i am on the steep end of the learning curve about unintended consequences of policies. And my thought about it is its a little like safety and edge kacy trials and medication develop ment. Do you phase one, safety and healthy individuals. Phase two, safety and individuals that are affected. Phase three, the randomized Clinical Trials and if theyre positive and encouraging, then you roll it out and you monitor to see what happens out in the real world. A third of the adverse events we hear about, we learn after market, after the fda approved. We do the same with poll sichlt we do our best as you saw to create policy based on the science of what seems like it will work. But when you roll it out in the real world, you dont know whats going to happen. I think its very important that we keep monitoring in the same way we try to monitor when we rollout a new drug to see if the new policies are having the intended effect or if there something we couldnt anticipate. And then make course corrections as we need to. Im just going to comment on the second question. Its actually not that im an exert on insurance but i read a lot about the issue of opioid medications and the use for chronic pain manage ment. I get emails from physician thats are experts on pain and say we completely agree with you with the recommendations of not using opioids as the first line of treatment which is what the cdc guidelines are sachlgt the problem that we have is that not all of the insurances actually cover for it and in the paperwork that is required in order to justify some of the alternative treatments which are considered first line of treatment for some of these pain conditions are not accepted by the insurance. So as a result of that, the physicians can not do the right thing because its nor cheaper to prescribe an opioid medication. So one of the things that is clear is, yes, we need to educate physicians of proper mana management of pain and proper use of the medications but we need to do structural changes into our Health Care System so that, the proper treatments are covered about it insurance. Because otherwise they can you write all of the guidelines that you want if someone is not going to reverse the patient, theyre not going to be given that intervention. So that is an aspect that we need to be very aware of. We generate a system that has favor now the way of treating that is far from opt maltha actually facilitates prescription of opioid over other interventions. Thank you. Yes . Ken dylan, cnc press. In the past the government of china does not appear to have been very tough in cracking down on suppliers of synthetic opioids. But im wondering if theres any evidence now that opioid addiction of this sort is spreading in china itself. And might that lead the government to become more serious . I dont have any evidence for that. I know that stimulants are very popular used and abused in Southeast Asia but not necessarily synthetic opioids. There is high level agreement to restrict a number of fentanyl and a number of others being exported from china. I would have to say that my own personal opinion is cynical on. That im not sure how one effectively controls the tiniest fraction of the of an i will l illicit production with enormous capacity and im not sure with even laws and regulations prohibiting the production how theyre going to pull it off. But its china. Maybe they will. I mean i want. I want supply control to happen. I really do. But it hasnt worked very effectively for drugs like cocaine and heroin in countries that have a lot less pull in the world than china does now. I fwhwas in china last year. We were trying to create new models of treatment for heroin and they have a very severe problem with heroin abuse. Bust theyve been quite successful on implementing their own clinics. I was interested exactly like you on that question. Are they seeing the consequences of this opioids . So i met with a director of the cdc and i asked him, you have started to see an increase in the number of overdose, dose thats may be pointing out to the fact that youre lacing heroin with fentanyl . He did not know about it. I think that is a very different country. And they have abilities of implemention interventions in ways that are much faster than us. But on the other one, i do not know the extent to which there is an accurate knowledge of the problem. I dont know how the system is. So we were surprised about it. From this side . Im from Pacific Northwest university. As a basic scientists. I get the value of the research both funneled. Al and clinical. Were doing our part at the university to better educate and have a professional approach. But it is disenheartening to see statistics like the private ensurers, 17 that are privately ensur insured are get the treatments that we dont have some effectiveness. And then you look at more rural populations, at risk populations, underserved medical kmunlt communities. And those numbers are more strikingly against us. Take that a step further. Thinking about the demand for these opioids and the connections with social bonding. Whats going on in our society and who will address some of the mover fundamental things that drive people to take a variety of different substanceors do certain behaviors in excess that harm them and also the community . Whos going to take responsibility for that . Dan, do you want to take responsibility for that . Ill start. The first part is i think we either have or will have a severe labor shortage in Substance Abuse treatment. There is simply not enough providers and the providers are not distributed in a way that meet the problem. I just have West Virginia in my head right now. So promoting medical education from medical school through residency could help. We certainly could also help with loan repayment or some other kinds of inventives that would promote a generation moving into psychiatry Mental Health addiction medicine i think would be tremendously helpful. As far as the second question goes, im actually writing a patient a paper with a couple colleagues right now looking at what are the deeper root issues of this . Because i agree with the line that were saying that excessive prescribing caused the wave effect that were in and that we need to turn that tap off. I love the example of the john snow example. We need to take the handle off the water pump. But theres a reason why this epidemic settled in the areas that it has settled into. Theres multiple asthma going on, multiple morbidity thats Say Something about this seg ment of american society. And whether its probably disenfranchisement, lack of future, lack of opportunity, lack of hope, there somewhat they call diseases of despair that are lining up in appalachian and over eastward. That is a much more complex set of problems that we need to address. But thanks for bringing that up. Ime im feeling despair, too. But i do go back to that hiv slide. That is that we did turn that epidemic around. So this specification epidemic, we vhave the Evidence Base and tools and we need resources and take the resources and apply them into the regions to get them to the area thats are having that might be culturally shifting to want to use opioid substitution therapy or this medically assisted treatment but may not have the experience or the personnel to do it. We can use creative approaches, telemedicine and the like to get. That i think we can address and turn around. The larger fault zone problem, im not quite so sure about. I would like to reiterate. That i think that in many ways i think that we need to end up in a very positive way. I actually look at it from the perspective of saying okay, what is the challenge that we have on addressing the Opioid Epidemic . We know how to do it. We have a road map that if we implement, we will succeed. I always put the counter argue ment. If someone were to tell me, how you would address a problem of the alzheimers . I wouldnt know how to start. We dont have treatments. We dont know how to properly prevent it. Here we have a much better understanding. We know where the epidemic generated. We know how it grows. We know how to prevent it and treat it. But it does require very intergrated approach of resources to do it. Weve done very successful campaigns on preventions of other drug use disorders. Look at tobacco, how we have dramatically reduced it. So we can do it. I mean obviously its going to require an investment. And one thing that is important because we havent been discussing it is we have the 21st century that is supporting a billion dollars for the treatment of opioid abuse disorders which is fantastic. Weve never seen anything like. That but the problem is we want to be sure that that funding goes for Evidence Based treatments for quality care which is not something that we really speak very much about in terms of these disorders. We speak about quality care on cancer. But not here. We need to demand that actually. Is there a way of improving the quality of care for people suffering from opioid abuse disorder or any other addiction. Thank you. Im going that take this one and then that and then well adjourn and go and enjoy our reception. Thanks. Im from john hopkins university, also a veteran u. S. Army. Thank you for your time today. Two short questions. One, it bults upon what youve been talking about. I wanted to the ask you from the va whether its Mining Industries or other industries, Auto Industries or any industries that seem to have slightly, you know, have been degenerated in the past century and past few years for new jobs. I think veterans face a transition crisis when they come out. Im wondering where are the programs now to have a civilian Health Care System that i can depend upon . I do get messages from the va. There is a lack of communication overall with the overall transition as veterans go in and out of different Health Care Systems to really understand what are some of the risks. Im wondering if can you touch upon that. Second part of the question is more specifically for the other members of the panel. You mentioned a lot of time today about heroin. But from the statistics of 2016 which are discussing the past year list of drugs among persons age 12 or older, marijuana is 2. 6 million, pain relievers are at 2. 1 million, cocaine is at 968,000, mda, 839,000, lsd at 664,000, and meth is at 225,000. Heroin is pretty low at 135,000. Im wondering. You talked about it on the last side about separating out that. From these statistics, ate pears that heroin is quite low on the scale. Are you doing a disservice . Id love for you to touch upon that as well. Thank you. May i take the first question first . Yeah. And we are going to have to be brief in our answers and brief in our questions. Okay. Id like to thank you for your service. And were a huge organization. And we do have [ no audio ] they ken gauge in health care with us. We also have programs so please contact us and let us help you. Thank you. [ inaudible ] okay. Thanks for bringing up the fact that, you know this is one piece of a much larger issue about american society. There are other drugs of misuse marijuana is not deadly than the more common drugs. We have to constantly remind ourselves that working with teens and vulnerable populations to reduce progression from what might be light level of alcohol use, Recreational Use or normal social use to not progress. Because people are testing genetics. Alcohol is highly genetic predisposition and people should know their family histories and magnify resilience factors to not progress. I just know heroin well. We need address it or there will be some major problems. Itting affect a piece of a generation. Can we go over here now . Ill try to keep this very brief. But thinking about what you just said about losing segments of generations and the previous comment. [ no audio ]
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