Disclosure Information Dr. Kevin Kunz has had no relevant financial - PowerPoint PPT Presentation

Disclosure Information • Dr. Kevin Kunz has had no relevant financial relationships with commercial interests within the ten years. • Dr. Kunz is the EVP of the American Board of Addiction Medicine and The Addiction Medicine Foundation: neither has ever accepted commercial, industry or Pharma support.

Osteopathic Physicians as Leaders in Addiction Medicine: Opportunities and Barriers Kevin Kunz, M.D., M.P.H., DFASAM OMED 2018 October 7, 2018

Session Objectives 1. Warm-up: One take on the basic science 2. Why field of addiction medicine (ADM) exists, and the need for more ADM subspecialists 3. Three concrete actions physicians can take to promote ADM in osteopathic practice, credentialing and education 4. Q&A

Warm Up 9 fast slides

What is Addiction? Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.

What is Addiction Medicine? • SUD Prevention & Screening • SUD and Sequelae Diagnosis & Treatment • Training & Education • Compassion, Patience, Professionalism Addiction Medicine physicians serve as: • Clinical experts • Faculty and teachers • Researchers and administrators • Health system and community change agents

ADDICTION INVOLVES MULTIPLE FACTORS EdwardSmith John Smith Susan Edwards ThomasSmith JohWalker Biology/Genes JaneWalker JaneJones James Smith JonathanCook JamesCook Amy Mason AnneCook Edward Bryson Beth Bryson Beth Carter John Smith Thomas Jones Walter Jones Rebecca Wilson John Jones William Price Alice Price Alice Benson Ann Jones Richard Hill Brain Mechanisms James Hill Mary Walters Mary Hill Steven Adams Susan Adams Allison Fields Addiction DRUG Environment

Understanding Addiction: Hedonic Tone

NORADRENALINE

Natural rewards and drugs activate Dopamine Neurotransmission in the brain’s reward centers

The mu Opioid Receptor . X X X X buprenorphine

Cocaine Dopamine D2 Meth Receptors are Lowered in Addiction Alcohol Heroin control addicted

Session Objectives 1. Warm-up: One take on the basic science 2. Why the field of addiction medicine (ADM) exists, and the need for more ADM subspecialists 3. Three concrete actions physicians can take to promote ADM in osteopathic practice, credentialing and education 4. Q&A

Annual Deaths from Substance Use* * CDC, 2016 Tobacco 480,000 deaths Rx & Illicit Opioids 44,000 deaths Alcohol 88,000 deaths Illicit Drugs 21,000 deaths

2.6 Million Total Annual U.S.

Opioids 1% All Other Causes 2.6 Million Total Annual U.S.

Opioids 1% Alcohol 3.5% All Other Causes 2.6 Million Total Annual U.S.

Opioids 1% Alcohol 3.5% Nicotine 19% All Other Causes 2.6 Million Total Annual U.S.

Opioids 1% Alcohol 3.5% Nicotine 19% Other Drugs ~1% All Other Causes 2.6 Million Total Annual U.S.

Percentage of All Annual Deaths Nicotine + Alcohol + Opioids, 2015 28 % 25% 29% 29% 30% 26% 22% 27% 22% 26% 28% 28% 28% 27% 28% 27% 30% 30 % 28% 23% 25 % 28% 28% 12% 29% 26% 24% 33% 28 % 23% 23% 25% 29% 29% 24% 25% 26% 25 % 29% 28% 27% 27% 25% 20% 19% 25% 24% 20% 23% 33% KEY KEY 23% 214 - 302 26 - 35 The United States of Drugs? 185 - 213 25 - 27 0 - 184 0 - 24

U.S. SUD Deaths & the 1918-19 Flu • 1918-19 Flu Pandemic – ~600,000 deaths – 25 % of the population infected, 20% death rate – Young adults and minority groups major victims: children and the elderly with less morbidity, mortality • 2016: 633,330 SUD deaths(CDC)

The Boiling Frog

Overdose Death Rates 2016 around 64,000 OD deaths: 22% increase from 2015 1999 2015 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System

Overdose Epidemic 60,000 Peak car crash deaths ‘72 Peak HIV deaths, 1995 40,000 Peak gun deaths, 1993 20,000

Fentanyl-Rela lated Deaths Su Surp rpassed Heroin in or r Rx x Opio ioid ids in in 2016 Graphs from NY Times Article based on CDC MMWR Report 2017

National rate of opioid-related inpatient stays and emergency department visits National rate of opioid-related inpatient stays increased 64.1% and ED visits 99.4% between Weiss et al., AHRQ, Center for Delivery, Organization , and Markets, Healthcare Cost 2005-2014 and Utilization Project 2017

Hospitalizations for Opioid Overdoses with/without Alcohol Source : Nationwide Inpatient Sample (NIS), unpublished

* * More than have heart conditions (27.0 million), More than have diabetes (25.8 million) More than have cancer (19.4 million)

Enormous Consequences of Unhealthy Substance Use & Addiction • Account for 32.3% of all hospital inpatient costs • 2016: US SUD cost exceeded $1Trillion • Are causal or contributing factors in over 150 medical conditions requiring acute and chronic care • Drive a wide range of other costly Social and Public Health consequences HEALTH CARE COSTS SOCIAL DISCORD PRODUCTIVITY LOSS VIOLENCE Medical CRIME, ACCIDENTS LOST OPPORTUNITIE S

Medical Illness Over 150 diseases caused or made worse by alcohol, nicotine and other drugs • Pulmonary • Cardiovascular • Infectious Diseases • Mental Illness • Cancer • Trauma and Unintentional Injuries • Brain: hardware and software • Etc. etc.

Child Abuse and Neglect Alcohol and drug problems are factors in 70% of child abuse and neglect cases.

The Criminal Justice System is driven by Alcohol and Drugs 80% of inmates have been incarcerated for alcohol or drug offenses, were intoxicated at the time of their offense, committed the offense to support their addiction, or had a history SUD

I in every 31 Adults is in CJS * * * One in every 100 American adults is incarcerated

Cost of Addiction Related Problems Sources: Prevalence – NSDUH (2014), NCI (2014), CDC (2012); Cost – CDC (2015), National Drug Intelligence Center - National Drug Threat Assessment (2011), 2014 Surgeon General’s Report, NHLBI (2012), Hutchinson 2017: Surpassed $1 Trillion et. al. 2006.

Treatment • Cognitive Behavioral Interventions 77% 73% 71% • Medications 11% • Chronic diseases Diabetes Hypertension Depression Addiction need long term care

Improving Implementation of Pharmacotherapy Treatment programs offering FDA 100% 90% approved SUD medications 80% 70% 60% 50% 40% 30% 25% 16% 19% 17% 20% 9% 9% 10% 0% Knudsen et al., J Addict Med 2011.

Opioid pharmacotherapy and mortality There was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002). Schwartz et al AJPH 2013

How Many ADM Subspecialists are Needed? • 7,500 ADM subspecialists needed by 2025 • 2009 TAMF White Paper, 2017 Update • Full Time • Current Numbers: – ABPM ADM Certified: 1,230 – ABAM Certified: 2,700 (200 DOs) – AOA ADM certified: 100?

Session Objectives 1. Warm-up: One take on the basic science 2. Why field of addiction medicine (ADM) exists, and the need for more ADM subspecialists 3. Three actions physicians can take to promote ADM in osteopathic practice, credentialing and education 4. Q&A

Three Concrete Actions 1. Practice Level: Remember that 48% of your patients have an SUD, or are at-risk substance users 2. Advocate and revolt for AOA ADM certification 3. Education: promote, establish or participate in an ADM fellowship

Attend to the patient, not only their disease or chief complaint.

CERTIFICATION • Addiction Medicine is a clinical subspecialty open to all ABMS board certified physicians • October, 2017. 1 st ABMS-ABPM ADM exam. 1,230 physicians certified in January, 2018 • October/November 2018. 2 nd ABMS-ABPM ADM exam. 1,000 expected to sit for the exam • Practice Pathway ends in 2021, thereafter eligibility for certification requires an ACGME accredited ADM fellowship

Advocate or revolt for AOA ADM certification Kunz, 2018 Addiction Medicine Certification Exams The following list includes scheduled Addiction Medicine OCC examinations. Select an item to view additional information and log in to apply, submit documentation or make a payment. If no exams are listed, please check back soon or contact the conjoint committee to find out when future exams will be offered. “contact the conjoint committee”

Addiction Medicine in AOA, ABMS AOA Conjoint Subspecialty of: ABMS Subspecialty of : Allergy and Immunology Anesthesiology • Family Medicine Colon and Rectal Surgery Dermatology • Internal Medicine Emergency Medicine Family Medicine • Neurology & Psychiatry internal Medicine Medical Genetics and Genomics Neurological Surgery Neurology Nuclear Medicine Obstetrics and Gynecology Conjoint Committee Members Ophthalmology Orthopaedic Surgery Otolaryngology – Joseph Brown, DO: IM Pathology Pediatrics – Ingrid Brown, DO: FM Physical Medicine and Rehabilitation Plastic Surgery – Roy Meland, DO: N&P Preventive Medicine Psychiatry Radiology Surgery Thoracic Surgery Urology