Realities of addiction_volkow-final
40
Reali&es of Addic&on Dr. Nora Volkow April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate
-
Upload
opunite -
Category
Health & Medicine
-
view
1.500 -
download
0
description
National Rx Drug Abuse Summit, April 2-4, 2013, General Session presentation "Realities of Addiction," by Dr. Nora Volkow, Director, National Institute on Drug Abuse
Transcript of Realities of addiction_volkow-final
Reali&es of Addic&on Dr. Nora Volkow
April 2 – 4, 2013 Omni Orlando Resort
at ChampionsGate
Learning Objec&ves
1. Iden=fy recent increasing trends in the misuse and abuse of prescrip=on drugs.
2. Describe the ways in which the most commonly abused prescrip=on drug classes affect the brain and body.
3. Explain strategies being developed and implemented that will increase awareness of the growing problem of addic=on.
Disclosure Statement
• Dr. Nora Volkow has no financial rela=onships with proprietary en==es that produce health care goods and services.
Nora D. Volkow, M.D. Director
Numbers in Millions
Prescrip&on Drug Misuse/Abuse is a Major Problem in the US Current Drug Use Rates in Persons Ages 12+
Source: SAMHSA, 2011 Na2onal Survey on Drug Use and Health`
Prevalence of Past Year Drug Use Among 12th graders 2012 Monitoring the Future Study
* Nonmedical use
Drug Prev. Drug Prev. Tranquilizers* 5.3
Marijuana/Hashish 36.4 Hallucinogens 4.8 Small Cigars 19.9 Seda&ves* 4.5 Hookah 18.3 Salvia 4.4 Synthe=c Marijuana 11.3 OxyCon&n* 4.3 Snus 7.9 Hall other than LSD 4.0 Narco2cs o/t Heroin* 7.9 MDMA (Ecstasy) 3.8 Amphetamines* 7.9 Inhalants 2.9 Adderall* 7.6 Cocaine (any form) 2.7 Vicodin* 7.5 Ritalin* 2.6 Cough Medicine* 5.6 LSD 2.4
Categories not mutually exclusive
0 100 200 300 400 500 600 700 800 900
1000 1100
0 1 2 3 4 5 hr Time After Amphetamine
% o
f Bas
al R
elea
se AMPHETAMINE
0 50
100 150 200
0 60 120 180 Time (min)
% o
f Bas
al R
elea
se
Empty Box Feeding
Di Chiara et al.
FOOD
VTA/SN nucleus accumbens
frontal cortex
These prescription drugs, like other drugs of abuse (cocaine, heroin, marijuana) raise brain dopamine levels
Dopamine Neurotransmission
Why Do People Abuse Prescription Drugs?
Opioids: Examples: OxyContin, Vicodin
Attach to opioid receptors in the brain and spinal cord, blocking the transmission of pain messages and causing an increase in the activity of dopamine
How They Work…
• Postsurgical pain relief • Management of acute or chronic
pain • Relief of coughs and diarrhea
Opioids are Generally Prescribed for:
Amydala (reward)
NAc (reward)
Thalamus (pain)
Similari&es Between Illicit and Prescrip&on Drugs
Stimulants
Enhance brain activity by increasing the activity of brain excitatory chemical messengers, such as norepinephrine and dopamine, leading to mental stimulation
Example: Ritalin How They Work…
• ADHD • Narcolepsy • Depression that does not
respond to other treatments • Asthma that does not
respond to other treatment
Stimulants Are Generally Prescribed For:
Methamphetamine
Adderall
Similari&es Between Illicit and Prescrip&on Drugs
• Expectation of Drug Effects Expectation of clinical benefits vs euphoria “high”
• Context of Administration School, clinic, home vs bar, discotheque
• Dose and Frequency of Dosing Lower, fixed regimes vs higher, escalating use
• Route of Administration Oral vs injection, smoking, snorting
What is the Difference Between Therapeutic Use and Abuse?
"High" "High" 0
20
40
60
80
100
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80
% P
eak
[11C]Cocaine
Time (min)
[11C]Methylphenidate
0 10 20 30 40 50 60 70 80
Rewarding Effects Depend on How Fast the Drug Gets into the Brain
0 0.01 0.02 0.03 0.04 0.05 0.06
0 20 40 60 80 100 120 Upt
ake
in S
tria
tum
(%/c
c)
Time (minutes) 0
0.01 0.02 0.03 0.04 0.05 0.06
Upt
ake
in S
tria
tum
(%/c
c)
0
0.0005
0.001
0.0015
0.002
0.0025
0.003
0.0035
0 20 40 60 80 100 120 Upt
ake
in S
tria
tum
(nC
i/cc)
Time (minutes)
iv cocaine iv Ritalin oral Ritalin
Rate of Drug Uptake Into the Brain
Cocaine (iv) and Ritalin (iv) produce a “high” but Ritalin (oral) does not.
The slow brain uptake of oral Ritalin permits effective treatment without a “high.”
0 20 40 60 80 100 120 Time (minutes)
Fast!!!Fast!!! Slow!!!
Source: Volkow, ND et al., Journal of Neuroscience, 23, pp. 11461-‐11468, December 2003.
Glucose Metabolism Was Greatly Increased By the Expecta2on of the Drug
Unexpected MP 70
0 µmol/100g/min
Expected MP
Increases in Metabolism Were About 50% Larger When MP Was Expected Than
Unexpected
0 5
10 15 20 25 30
% C
hang
e
Une
xpected
MP
Expe
cted
MP
Expe
cted
MP
Got Placebo
What Has Raised Our AUen2on to the Problem of Prescrip2on Drug Abuse?
Source: SAMHSA Treatment Episode Data Set (TEDS), 2000-2010
28,326 37,649
45,882 52,664
60,824 71,048
82,359
98,386
122,185
142,124
157,171
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
More Than 5-Fold Increase In Treatment Admissions For
Prescription Painkillers In the Past Decade
12
10
8
6
4
2
0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 *Deaths are those for which poisoning by drugs (illicit, prescrip=on, and over-‐the-‐counter) was the underlying cause.
Drug Overdose Death Rates in the US Have More Than Tripled since 1990
Na&onal Vital Sta&s&cs System. Drug Overdose Death Rates by State 2008.
100 people die from drug overdoses every day in the US
35,00
0
30,00
0
25,00
0
20,00
0
15,00
0
10,00
0
5,000
0 Num
ber of ED Visits
9,000
6,000
3,000
0 Aged 5 to 11 Aged 12 to 17 Aged 18 to 25 Aged 26 to 34 Aged 35 or Older
2005 2010
3,322 3,791
2,702 3,461
2,131
8,148
1,754
6,094
2,519
7,957
Num
ber of ED Visits
2005 2006 2007 2008 2009 2010
4,315 6,332
11,390 11,448 12,208 14,068
17,174 14,503
12,287 14,979
10,614 9,059
13,379 16,948
26,369 23,735
26,711
31,244
All Males Females
Emergency Department (ED) Visits Related to Stimulant Medications
Source: SAMHSA Dawn Report:Emergency Department Visits Involving AUen2on Deficit/ Hyperac2vity Disorder S2mulant Medica2ons , January 24, 2013.
Data in Several States Show That Hepatitis C Virus Among Adolescents and Young Adults
Has Increased in Recent Years Of cases with available risk data, injec2on drug use (IDU) was the most common risk factor for HCV transmission Although only a small number of these cases responded to further inves2ga2on…..
• 92% reported opioid analgesic abuse • 89% reported heroin use • 95% used opioid analgesics before switching to heroin • During the preceding 6 months, the most frequently injected drugs were heroin (50%) and opioid analgesics (30%)
CDC, MMWR, May 6, 2011/60(17); 537-541; CDC, MMWR, October 28, 2011/60(42):1457-‐1458
Number of Opioid Prescriptions Dispensed by U.S. Retail Pharmacies, Years 1991-2011
76 78 80 86 91 96 100 109
120 131
139 144 151
158 169
180 192
201 202 210
219
0
50
100
150
200
250 91
92
93
94
95
96
97
98
99
20
00
01
02
03
04
05
06
07
08
09
10
11
Pres
crip
tions
(mill
ions
)
IMS’s Source Prescription Audit (SPA) & Vector One®: National (VONA)
Opioids Hydrocodone Oxycodone
Oxycodone and Hydrocodone Prescriptions 1998-2012
Codeine & Comb NON-INJ (USC 02232), Morphine & Opium NON-INJ (USC 0222), Morphine & Opium INJ (USC 02221), Codeine & Comb INJ (USC 02231). Source: SDI Health, VONA
16 19 22 25 27 29 31 34 38 43 47 49 54 57 57 72
83 90 96 101 106 110 120 126 132 133 130 131 136 134
0
20
40
60
80
100
120
140
160
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Mill
ions
Oxycodone (Schedule II) Hydrocodone (Schedule III)
Opioid Prescriptions by Age
2 6
19
30
159
-
20
40
60
80
100
120
140
160
180
-
5
10
15
20
25
30
35
2002 2006 2009 2012
No.
of P
resc
ript
ions
, Age
40+
(mill
ions
)
No.
of P
resc
ript
ions
(mill
ions
)
0 to 9 10 to 19 20 to 29 30 to 39 40+
IMS Health, Vector One® National
Opioids Overdose Death by Age Group,
US, 2008
Rate per 100,000
Paulozzi LJ, J Safety Res 2012; 43(4): 283-289.
20% 15%
11% 10%
9%
27% 12% 11%
8% 5%
20% 16%
11% 9%
6%
20% 13%
9% 8% 7%
16% 12%
7% 6%
3%
0 0.1 0.2 0.3
Percentage of Prescriptions Dispensed for Opioid Analgesics from Outpatient US Retail Pharmacies, by Age Group
2006 2002 22%
16% 11% 10%
8%
27% 12% 11%
8% 5%
19% 18%
12% 8% 7%
24% 12%
10% 8% 7%
26% 17%
9% 7%
4%
0 0.2
0 to 9
10 to 19
20 to 29
30 to 39
≥40
EN Phys Pediatrician Dentist Emerg Med GP/FM/DO Ortho Surg OB/GYN Intern Med Anesthes
IMS Health, Vector One® National
23% 16%
13% 11%
6%
29% 12%
8% 8% 6%
17% 16%
13% 8% 8%
21% 10% 9% 8% 7%
25% 16%
7% 6% 6%
-‐10% 10% 30%
2012
Top Prescribers of Opioid Analgesics in 2012
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pres
crip
tions
GP/FM/DO
Internal medicine
Dentistry
Orthopedic Surgery
IMS Health, Vector One® National
Percen
t
Source: 2010 Na2onal Survey on Drug Use and Health, SAMHSA 2011.
Source of Prescrip&on Drugs (how they obtained the drugs they most recently used nonmedically) Rates averaged across 2009 and 2010
Jones, CM et al. JAMA, February 20, 2013; 309(7): 657-659.
National Center for Health Statistics show drug overdose deaths increased for the 11th consecutive year in 2010
In 2010, there were 38,329 drug overdose
deaths in the United States
Percentage of Overdose Deaths for Specific Psychotherapeu=c and CNS Pharmaceu=cals that Involved a Single Drug Class, US, 2010
Psyc
hoth
erap
eutic
and
C
NS
Phar
mac
eutic
als,
%
Opioid Analgesics (n=16,651)
An&epilep&c & An&parkinsonism
Drugs (n=1,717)
Benzodizepines (n=6,497)
Barbiturates (n=296)
An&depressants (n=3,889)
An&psycho&c & Neurolep&c
Drugs (n=1,351)
Other Psychotropic
Drugs (n=24)
35
30
25
20
15
10
5
0
Jones, CM et al. JAMA, February 20, 2013; 309(7): 657-659.
PER
CE
NT
Drug Involvement in Pharmaceu=cal Overdose Deaths Opioid Analgesic Involvement in Deaths for Specific Drugs
Specific Drug Involvement in Pharmaceu&cal Overdose Deaths USA, 2010
75.2
7.8
29.4
1.3
17.6 6.1
0.1
100
65.5 77.2
50 57.6 58 54.2
0
20
40
60
80
100
120
How to Minimize the Diversion and Abuse of Prescription Medications
Engage the Healthcare System
Doctors Need to Know… What Opioid Prescriptions Have Been Given to
Their Patients By Other Doctors or Practitioners
This information should be:
1) included in the patients’ electronic health care records
2) accessible through a Prescription Drug Monitoring Program (PDMP) that provides immediate information and can cross-reference across States
Mezei, L and Murinson, BB., J Pain, 12, 1199 -‐1208, 2011.
Education on Pain in Medical Schools
Number of Hours of Pain Education
Num
ber of Schoo
ls
USA (median: 7 hours) Canada (median: 14 hours)
Veterinarian schools: 75 hours on pain
0-5 5-10 10-15 15-20 20-25 25-30 >30
• Centers of Excellence in Pain Education (12 CoEPE)
• Consensus Workshop on Opioids for Chronic Pain
ICs Involved: ORWH NIA OBSSR NINR NIDA NICHD NIDCR NIAMS NINDS NCCAM
• Efficacy of opioids for treating chronic pain • How to administer opioids for optimal efficacy and minimal adverse effects • Risks for addiction • Populations differences • What training is available (other than offered by industry) for teaching how and what type of opioids should be used in managing chronic pain?
• What research directions need to be pursued to determine best approaches for managing chronic pain with opioids? • For research gaps, what are research priorities?
Consensus Workshop: Opioids for Chronic Pain
Prevention Strategies – Public Education CME Courses developed by NIDA & Medscape Education, funded by ONDCP
Safe Prescribing for Pain Managing Pain Pa&ents Who Abuse Rx Drugs
Skills and tools clinicians can use to screen for and prevent abuse in pa7ents with pain
Learn symptoms of opioid addic7on and dependence in pa7ents with chronic pain, and how to screen for, prevent and treat such condi7ons
Pain Medica&ons
• Develop medications with slower abuse potential including drugs that don’t cross BBB (i.e., CBR2 agonist)
• Develop slow release formulations (low dose and long duration)
• Develop novel formulations to reduce abuse liability including mixture formulations (e.g., naloxone and buprenorphine)
0 0.0005 0.001
0.0015 0.002
0.0025 0.003
0.0035
0 20 40 60 80 100 120 Upt
ake
in S
tria
tum
(nC
i/cc)
Time (minutes)
Slow!!!
Prevention Strategies – Overdose Intervention
• Naloxone Distribution for opioid overdose victims. The potential for direct intervention to save lives.
• Naloxone Nasal Spray Development
Needle-free, unit-dose, ready-to-use opioid overdose antidote
NIDA STTR Grantee – An7Op, Inc., Daniel Wermeling, CEO Contact: E-‐mail: [email protected], Tel: 859-‐221-‐4138
Treatment of Addiction to Prescription Opioids
Buprenorphine
Currently 19,000 physicians are certified to prescribe buprenorphine (Source: CSAT Buprenorphine Information Center)
Targets the same opioid receptors as morphine (mu) but its much less potent, has a much longer half life and does not produce the same high as heroin or morphine
Universal Drug Abuse Prevention May Reduce Prescription Drug Misuse
Spoth et al., Addiction 2008;103(7):1160-1168. Spoth, et al., AJPM 2011;40(4):440-447
For 100 young adults in general population starting Rx abuse, only 35 young adults from an intervention community started.
Overall, three studies now suggest the impact of universal prevention on prescription drug abuse.
www.drugabuse.gov
Num
bers in Tho
usan
ds
Source: 2011 Na2onal Survey on Drug Use and Health, SAMHSA, 2012.
Large Number of Past Year Initiates of Pharmaceuticals: Persons Aged 12 or Older, 2011
Marijuana Pain Relievers
Tranquilizers Ecstasy
Inhalants Cocaine
Stimulants LSD
Heroin Sedatives
PCP
Overdoses of prescription painkillers have more than tripled in the past 20 years, killing more than 15,500 people in the US in 2009
For every overdose death from prescrip=on painkillers
there are
treatment admissions for abuse
emergency department visits for misuse or abuse
people who abuse or are dependent
people who take prescrip=on painkillers for non-‐medical use
10
32
130
825
