Heroin Addiction and · PDF fileHeroin Addiction and Overdose: ... conducting clinical trials...
Transcript of Heroin Addiction and · PDF fileHeroin Addiction and Overdose: ... conducting clinical trials...
Nora D. Volkow, M.D.Director
Heroin Addiction and Overdose:What Can We Do to Address This Growing Problem?
Numbers in Millions
Prescription Drug Misuse/Abuse is a Major Problem in the US
Source: SAMHSA, 2013 National Survey on Drug Use and Health, 2014.
0.3
0.5
1.3
1.5
6.5
19.8
24.6
0 10 20 30
Heroin
Inhalants
Hallucinogens
Cocaine
Psychotherapeutics
Marijuana
Illicit Drugs4.7
4.95.1 5
4.8 4.9 4.8
4.3
4.8
4.2
2.1 2.2 2.1 2.1 22.2 2.2
22.3
2
1.2 1.11.4
1.2 1.1 1.2 1.1 11.3 1.3
0.3 0.3 0.4 0.3 0.2 0.3 0.40.2 0.2 0.2
0
1
2
3
4
5
6
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Current Drug Use Rates in Persons Ages 12+
Perc
ent
Past Year Nonmedical Use of Psychotherapeutic Drugs
Persons Ages 12+
High Levels of Opioid Prescriptions have Facilitated Diversion & Contributed to Overdose Deaths
4,0304,400
5,528
7,456
8,517
9,857
10,928
13,72314,408
14,80015,597
16,65116,91716,00716,235
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Rx Opioid Overdose Deaths
Total Female Male
Source: CDC Wonder
Oxycodone & Hydrocodone Prescriptions
16 19 22 25 27 29 31 34 3843 47 49
54 57 57
7283
9096
101106 110
120126
132 133 130 131136 134
0
20
40
60
80
100
120
140
160
Mill
ions
Oxycodone (Schedule II)Hydrocodone (Schedule III)
SDI Health, VONA_02-1-13_Opioids Schedule II & III
Past Month &Past Year Heroin Use Persons Aged 12 or Older
SAMHSA, 2012 National Survey on Drug Use and Health, 2014.
404
314
398379
560
373
455
582621 620
669 681
166
119
166136
339
161
213193
239281
335
289
0
100
200
300
400
500
600
700
800
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Past Year
Past Month
Num
bers
in T
hous
ands
1,960 1,842 1,7792,089 2,080
1,878 2,009 2,0882,399
3,0413,278
3,036
4,397
5,925
8,257
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
Heroin Overdose Deaths Total Female Male
Source: CDC Wonder
Abuse of Opioid Medications has led to a Rise in Heroin Abuse and Associated Deaths from Overdoses
Respondents Who Endorsed Past-MonthUse of OxyContin or Heroin
Before and After Introduction ofan Abuse-Deterrent Formulation (ADF)
Drugs Used to Replace OxyContin After the Introduction
of the Abuse-Deterrent Formulation (ADF)
60
50
40
30
20
10
0
Past
-Mon
th A
buse
Am
ong
SKIP
Res
pond
ents
, %
Jan-Jun2009
Jul-Dec Jan-Jun2010
Jul-Dec Jan-Jun2011
Jul-Dec Jan-Jun2012
Jul-Dec Jan-Jun2013
Jul-Dec Jan-Jun2014
ADF Release Heroin
OxyContin
RA
PID
Res
pond
ents
, %
80
70
60
50
40
30
20
10
0
Drug Selected to Replace OxyContin
Cicero TJ and Ellis MS JAMA Psychiatry. Published Online March 11, 2015.
Analgesic Mechanisms of Mu Opiate Drugs (Heroin, Vicodin, Morphine)
Thalamus(pain)
ACC(pain) PAG
(pain)
Accumbens(reward)
How Can Research Help?
• PAIN: Develop Less Abusable Analgesicsand Alternative Therapeutics
• OVERDOSES: User Friendly Naloxone
• ADDICTION: New Medications and Immunotherapies
• Pharmacogenomics (Precision Medicine)
• Implementation Science
Develop Less Abusable Drugs:Prodrugs
• Problem: changing method of taking opioids – i.e., crushing, injecting – increases euphoria; abuse
• Challenge: develop drugs that resist tampering; abuse
• Research response: oxycodone prodrug– Inactive compounds metabolized in the body to
produce active drug
Transcranial Direct Current Simulation (tDCS)
High-Definition transcranialDirect Current Stimulation (HD-tDCS)
Morena-Duarte I et al., Neuroimage 2014; 85(3): 1003-1013.
Non-Medication Strategies for the Treatment of PAIN and ADDICTION
Left sensory thalamusLeft periventricular gray
Gray AM et al., J Pain 2014; 15(3): 283-292.
Deep Brain Stimulation (DBS)Stereotaxtic implantation of
electrodes that emit electrical stimulation to a targeted
neuronal region
Transcranial Magnetic Stimulation (TMS)
PAIN: Alternative Therapeutics
Improving OD Treatments:Naloxone for Overdose
• Lay-friendly administration: intranasal naloxone
• AntiOp, developing disposable naloxone nasal spray. Product could be on the market 2015
• Lightlake Therapeutics, conducting clinical trials with intranasal naloxone for binge eating disorder will test this for opioid overdose
Improving Implementation of Medication Assisted Treatments: Addiction
25%
9%17%
9%16% 19%
0%10%20%30%40%50%60%70%80%90%
100%
% Treatment Programs Offering FDA-approved SUD
medications
Methadone26.4%
Buprenorphine3.9%
Vivitrol0.3%
Not receiving Methadone,
Buprenorphine or Vivitrol
69.4%
% OTP patients receiving methadone, buprenorphine,
or vivitrol
Knudsen et al., J Addict Med 2011. 2012 N-SSATS Data, SAMHSA
Opioid Agonist Treatments Decreased Heroin OD Deaths
Baltimore, Maryland, 1995-2009
Heroin overdoses Buprenorphine patientsMethadone patients
Rosenthal RN et al., Addiction 2013;105: 2141-2149.
Buprenorphine Implants
Placebo
Sublingual Buprenorphine
Challenge: Compliance with daily intakeSolution: develop long acting medications
Schwartz RP et al., Am J Public Health 2013.
ADDICTION: New Medications & ImmunotherapiesRCT Buprenorphine Implants
vs Placebo & Sublingual Buprenorphine/Naloxone
…………………….........Probuphine is designed to release sustained therapeutic drug levels in patients with opioid addiction for up to six months
% o
f Pat
ient
s Fai
ling
to E
xcee
d E
ach
Poss
ible
Cri
teri
on o
f Suc
cess
% of Urines Negative (out of 72) for Opioids Across Weeks 1 to 24
Antibodies reduce amount of drug in the brain
CapillaryBlood Flow
Brain
Treating Opioid Addiction: Vaccines
Targets drugs, not receptors
CapillaryBlood Flow
Brain
Antibodies
Vaccine
Binding sites
• Responsible Prescribing and Managementof Chronic Pain, which requires enhanced Education on Pain and its Treatment
• Availability of Naloxone
• Mandatory Addiction Education in Medical, Nursing and Pharmacy Schools
Strategies that Can Help Address the Dangers of Opioid Overdose and Addiction in the US
Implementation Science
National Pain Strategy
”HHS Secretary should develop a comprehensive, population health-level strategy for pain prevention, treatment, management, education, reimbursementand research ..."
NIH Pain ConsortiumCenters of Excellencein Pain Education
Goal: Improve pain treatment through education
• NIDA CoEs established in 2007 to help fill gaps in medical education curricula related to both illicit drugs and Rx drug abuse
• Medical schools at CoEs have developed a diverse portfolio of innovative curriculum resources about how to identify and treat patients struggling with SUD
Resources for Medical Students, Resident Physicians & Faculty
NIDA
Walley AY et al., BMJ 2013; Published 31 January 2013.
Opioid Overdose Death Rates Were ReducedIn Communities Where Overdose Education & Nasal
Naloxone Distribution Program (OEND) Was Implemented Unadjusted Unintentional
Opioid-Related Overdose Death Rates
Unadjusted Opioid-Related Acute Care Hospital Utilization Rates
Which Drug is the First Opioid Used in Addicts? Shifting Pattern of Heroin vs. Rx Opioid First
Percentage of Heroin-Addicted Treatment Admissions that Used Heroin or Prescription Opioid as First Opioid
Source: Cicero et al. JAMA Psychiatry. 2014;71(7):821-826
1960s: more than 80%started with heroin
2000s: 75% started with prescription opioids
2010-2013: Increasing initiation with heroin
100
90
80
70
60
50
40
30
20
10
01960s 1970s 1980s 1990s 2000s 2010s
(n=88) (n=114) (n=214) (n=482) (n=1613) (n=286)Decade of First Opioid Use (No. of Abusers)
Tota
l Sam
ple,
%
` Prescription OpioidHeroin
`
``
`
`
`
Age-Adjusted Rates for Drug-Poisoning Deaths Involving
Heroin, By Census Region: US
CDC, NCHS Data Brief, No 190, March 2015.
Dea
ths p
er 1
00,0
00 p
opul
atio
n
Northeast Midwest South West
5
4
3
2
1
0
20002007 2013
Northeast
Rates for Drug-Poisoning DeathsInvolving Heroin, By SelectedAge & Race & Ethnicity Groups
Dea
ths p
er 1
00,0
00 p
opul
atio
n
20002013
8
7
6
5
4
3
2
1
0 18-44 45-64 18-44 45-64 18-44 45-64
Non-HispanicWhite
Non-HispanicBlack
Hispanic
CDC, NCHS Data Brief, No 190, March 2015.
Possible Consequences of Heroin UseIncreased Risk of Contracting Infectious Diseases including:HIV/AIDSHepatitis B and C
Incidence of acute hepatitis Cby age group, U.S., 2000-2011
0
0.5
1
1.5
2
2.5
3
Rep
orte
d ca
ses/
100,
000
popu
latio
n
0–19 yrs
20–29 yrs
30–39 yrs
40–49 yrs
50–59 yrs
≥60 yrs
Source: National Notifiable Diseases Surveillance System (NNDSS), CDC