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