Elephants, eBay, and Outline Lincolns beard Where are we? - PDF document

12/9/16 Elephants, eBay, and Outline Lincoln’s beard • Where are we? • Statistics • HIV and opiate epidemics • New wave of opiates • MAT and other tx considerations Clinical Review of the Opioid Epidemic • Now what? Katherine Grieco DO 12/16 “Now it’s everybody’s problem, got a nation on the verge…” • https://www.youtube.com/watch?v=fYN14UfO-Uc I have no disclosures. • Macklemore – “Drug Dealer” 1

12/9/16 Ho How w did did we e get t her here? e? The ‘State of the Union’ Th • “Providers did this.” • 21 million Americans have a substance use disorder • Pharma • 40% of those with SUD have mental illness • Less than ½ receive tx for either • DEA • 90% of those who need tx for SUD do not receive it. • America’s perception • One in 5 Americans have experienced mental illness in past year • Suicide rate surges to 30-year high (many involve opiates) • Overdoses (accidental and intentional) d/t Rx opiate pills and heroin are skyrocketing Nu Number o of O Opiate P Prescr criptions Di Dispensed This crisis has not yet peaked NIH 2014 2

12/9/16 CDC: US Overdose deaths 2005-2014 Growing Epidemic • 125 Americans die/day from OD, more • Appalachia than MVA; one every 12-15 min • Work-related injuries – blue collar • 2014 – most overdose deaths than • Southwest any other year on record • Proximity to Mexico • 6 out of 10 involved an opiate • Northern California • 1999-2012: overdoses with Vicodin, Percocet, Oxycontin quadrupled • 2007-2014: heroin use tripled • 2010 -2014: heroin deaths tripled BLUE: 4 deaths per 100,000 RED: 20 deaths per 100,000 CDC – Epidemics, HIV V vs Opiates California • Per CDC, similar to HIV epidemic, 1995. • Mostly rural counties • HIV deaths rose in shorter time frame, more urban. • Mariposa • Opiate crisis crosses into rural regions • Lake • TOUGHER TO TREAT - ACCESS • Plumas • Increase in HIV, MMWR 4/15 • Humboldt • Indiana – Opana • Mendocino • Increase in HCV, MMWR 5/15 • Appalachia BLUE: 4 deaths per 100,000 • 4-fold increase in HCV infections 2006-2012 in 4 states RED: 20 deaths per 100,000 • Increase in admissions for opiate tx, & injection use • “Highly correlated with region’s opioid epidemic abuse” 3

12/9/16 Ba Barri rriers s to care – Insurance, finances Fe Federal Response • Unequal coverage between MH/SUD and medical care • Mental Health and Substance Use Disorder Parity Task Force • Co-pays • Created by Obama March 2016 • Number of monthly visits limited • Guidance for health insurers, state regulators • Refusal to cover inpt rehab without completing outpt program • Enhance parity compliance and enforcement (audits, penalties) • Raising limit on Suboxone waivers • Longterm Rehabs denying MAT admissions (medication assisted tx) • Increasing access to Narcan • ABC documentary – David Muir • DEA – Cut opioid production by 25% • Affects Schedule II: oxy, hydrocodone, fentanyl, morphine • CDC pain guidelines • Vermont – tx waiting list of 500 pts, likely wait a year • Downstream Effect • Surgeon General’s Report on Alcohol, Drugs, Health 11/16 • Prior authorizations for MAT • Cigna • Facing Addiction in America • 10/16: Attorney General NY – Eric Schneiderman Wh Where’s s the mon money? Treatment Law Enforcement $ Recent Law Enforcement Treatment $ Future 4

12/9/16 Changing the Language of Addiction Changing the Language of Addiction “Addict” • Office of Drug Control and Policy “Dirty” or “clean” urine • Draft – guidance on how to do this • Clinical, non stigmatizing language “Alcoholic” • First person language “Addict” vs person who uses drugs (PWUD) “Crackhead” “Alcoholic” vs someone who has alcohol use disorder “Crackhead” vs someone who uses cocaine Psych – “schizophrenic” • Less shaming words Med – “diabetic” “Dirty” or “clean” urine vs positive or negative for… “Abuse” vs misuse • JAMA October 2016 • National Press Foundation • Case vignette – substance abuser vs person with SUD • Pts often refer to themselves with these terms • Punitive vs therapeutic measures • Teaching opportunity Question • Where are the majority of synthetic opiates and designer drugs developed? Synthetic Opiates • A) US– clandestine labs in the Southwest (ie Breaking Bad) • B) Mexico – highly organized drug cartel (ie El Chapo) • C) China – chemists browsing old chemistry journals • D) Middle East – corrupt pharmaceuticals 5

12/9/16 “Flatline, Drop Dead, Bud Ice” Fentanyl Fentanyl-laced heroin • Fentanyl – 50-100x more potent than heroin • New Haven, CT public health emergency • Very fast-acting, victims OD w/ needle still in arm • 6/23/16: ~20 OD, 3 deaths in 6 hours • Colorless, odorless • Seeking cocaine • Per users: • Cincinatti: 174 OD in 6 days • Looks concrete/gray (vs powder white) • Massachusetts: 66% OD deaths in 2016 • Tastes bitter • Pittsburgh: 22 OD in 10 days • Sometimes identified by stamp –ladybug • California: Sacramento County • Laced blotter paper • 10 deaths, 4/16 Send-out urine test • Counterfeit Norco M367 • San Francisco: 75 deaths 7/15, most related to fentanyl Carfentanil Carfentanil • Case report of veterinarian splashed in face • Analog of fentanyl • Drowsy within minutes and required narcan • 10,000x more potent than morphine • Transported from China and Mexico • 100x more potent than fentanyl • Confirmed cases in OH, FL • Schedule II narcotic, not intended for human use • First responders, law enforcement • Used to tranquilize elephants and • Must wear protective gear other large mammals – Wildnil • Require several doses of Narcan • Lethal amount – 2mg to revive • Lincoln’s beard on penny • No way to test in urine 6

12/9/16 W-18 U-47700 • University of Alberta in Canada, 1981 • Opiate analgesic, no clinical indication – tested only in mice • Opioid, 8x more potent than morphine • Published in journal at the time • Potency similar to carfentanil • 1970’s - Upjohn Pharmaceuticals • Researcher Brent Warren • Alternative to morphine • 2015 – Calvary • Identified in 21 states (CA) • Law enforcement seized several pills laced with W-18 • First publicized seizure in North America • 46 deaths across the US • 2016 – Florida • NY, NC • Man arrested for possession of W-18 • Starting to creep into the US. No way to test in urine • Schedule 1 as of 11/14/16 • China • Rogue chemists search old journals to find compounds they can synthesize Whack-a-Mole Counterfeit Xanax • Cut with fentanyl • Emerged end of 2015 – several cases in US including • Poor detection of Synthetic Opiates deaths • Difficult to detect in bodily fluids • Infant ingested pill found on the floor • Concentrations are incredibly low • Manufacturures bought Xanax stamp on eBay • DEA is challenged to keep up with analogs analogs • Those seeking Xanax aren’t the same population seeking opiates • May not have tolerance to opiates Lethality is exceeding detectability • Results in overdose Educate your patients 7

12/9/16 Question • Which of the following are currently approved medications for Opioid Use Disorder? Medication Assisted Treatment and other Tx considerations • A) Methadone, buprenorphine, naloxone • B) Methadone, buprenorphine, acamprosate, naltrexone • C) Methadone, buprenorphine, naltrexone • D) Methadone, buprenorphine, clonidine MAT: Pharmacotherapy plus counseling and behavioral therapies MAT for Opiate Use Disorder – Options Probuphine Buprenorphine/naloxone Methadone maintenance Naltrexone (Suboxone, Bunavail, Zubsolv) (MMTP) • Opioid blocker • NO risk for OD Partial opioid agonist Full opioid agonist • • • FDA approved May 2016 • Pill or injection (Vivitrol) Ceiling effect – resp depression, Higher risk for OD, • • • Office based sedation sedation • Long acting buprenorphine subdermal implant, 6 months • Pts who are having cravings, not Films or Pills (buprenorphine – Liquid form, daily dosing • • experiencing any withdrawal, • Physician-certified, minor procedure – upper arm Subutex) Federally qualified OTP • not currently using Office based tx (opiate tx program) • • Pre-requisite • Stable pts - no poly drug use, Stable pts – no poly drug use, Highly regulated, structure • • support system in place , support system in place , Counseling mandated • Stable on buprenorphine/suboxone 8/2mg daily for at least 3 months • psychologically stable (not for psychologically stable Pts in need of monitoring, • • Still recommend monthly visits for ongoing counseling and pts who have failed MMTP MUST be in withdrawal to start lack of support system, • psychosocial support and/or Suboxone) Probuphine – next slide psychologically unstable, • failed Suboxone Withdrawal not necessary • to start 8