Understanding the Overdose Crisis: Science, Stigma, and Solutions Sarah E. Wakeman, MD, FASAM Medical Director, MGH Substance Use Disorder Initiative Co-chair, MGH Opioid task Force Clinical Co-lead, Partners Healthcare Substance Use Disorder Initiative Director, Addiction Medicine Fellowship Assistant Professor, Harvard Medical School
Di Disclosu closures res • Research support funding from OptumLabs
Obj bjec ectives tives 1. Describe the evolving landscape of the overdose crisis, highlighting recent epidemiologic data associated with overdose mortality 2. Review effective harm reduction and treatment interventions for those with opioid use disorder 3. Compare and contrast systems of care for people with substance use disorder compared to other medical conditions
Drug overdose now leading cause of death for Americans under 50
In Increase in in Opioid Prescribing Was Corr rrelated wit ith Overdose & Rx OUD Paulozzi LJ, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers — United States, 1999 – 2008. MMWR Morb Mortal Wkly Rep 2011;60:1487 – 92.
Ongoing Death Toll ll Due to Heroin/Fentanyl Hedegaard H. NCHS Data Brief, no 329. 2018.
In 2017, overdose deaths increased by ~10% Ev Evol olution ution Opioids involved in over two-thirds of overdose of of the he deaths Dr Drug ug Illicitly manufactured fentanyl drove increase, while heroin and prescription-opioid related deaths Over Ov erdose dose remained stable Epide Ep demic mic Rates of overdose deaths from cocaine and stimulants increased by 34 % & 33% respectively Largest relative change occurred among black Americans (increase by 25.2%) and largest absolute rate increase was among males aged 25 – 44 years Scholl L, et al. MMWR Morb Mortal Wkly Rep 2019;67:1419 – 1427.
Ov Over erdose dose Do Does es Di Discr criminate iminate • Those at greatest risk of death often most marginalized • People experiencing incarceration, homelessness, serious mental illness have markedly higher rates of overdose death • Treatment models not designed with these populations in mind MA DPH. https://www.mass.gov/files/documents/2017/08/31/legislative-report-chapter-55-aug-2017.pdf
“As we have seen repeatedly in the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid [overdose] epidemic will not be any different.”
Stereotypes of f Addiction Im Impact Practice and Polic licy “For me the most educational experience of the past three decades was to learn that the traditional image of the [person with addiction as having] weak character, hedonistic, unreliable, depraved, and dangerous is totally false. This myth, believed by the majority of the medical profession and the general public, has distorted public policy for seventy years.” Dr. Dole Dole, VP. Drug and Alcohol Review. 1994; 13: pp. 3-4.
• “The question is frequently asked: Why does a man become a [person with addiction]? The answer is that he Un Understanding erstanding usually does not intend to. Junk wins by default. I tried it as a matter of Addictio iction curiosity. I drifted along taking shots when I could score. I ended up hooked. You don’t decide to [develop addiction]. One morning you wake up sick and you’re [addicted]. ” • William Burroughs, 1953
Na Natur ural al Hi History tory of of Op Opioi oid d Us Use e Di Disord order er Euphoric Normal Sick
A Disease of Gene-Environment- Development Biology Environment Genes/Development DRUG/ALCOHOL Brain Mechanisms Slide courtesy of Dr. Compton, NIDA Addiction
Ad Addi dicti ction on • Primary, chronic disease characterized by compulsive drug seeking and use despite harmful consequences • Involves cycles of recurrence and remission • 40-60% genetic American Society of Addiction Medicine. April 12, 2011. www.asam.org NIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction
Substance Use Disorder is often a Chronic, but Treatable Illness Decreased Brain Metabolism Decreased Heart Metabolism in in Substance Use Disorder Coronary Artery Disease High Low Healthy Brain Healthy heart Diseased Brain Diseased Heart Slide Courtesy of NIDA
Visualiz ualizing ing Re Recove overy ry Volkow et al. J. Neurosci., December 1, 2001, 21(23):9414 – 9418
Tr Treatment atment Ou Outcome tcomes s as Go Good od as fo for Ot Other er Chroni ronic c Dis iseases eases NIDA. Principles of Drug Addiction Treatment. 2012. McLellan et al., JAMA, 284:1689-1695, 2000 .
Si Simi milar ar to o Ma Mana nage geme ment nt of of Di Diab abet etes es or or HI HIV • No cure • Goal is to prevent acute and chronic complications • Individualized treatment plans and goals • Treatment includes: • Medication • Lifestyle changes • Regular monitoring for complications • Behavioral support
Le Lear arnin ning g Fr From om Ot Othe her Ep Epide demic mics: s: HI HIV/ V/AI AIDS DS https://endinghiv.org.nz/
Lessons ssons fr from m HIV IV/AI /AIDS DS • Early Years: Free Fall “Recent advances have obscured the difficult and often demoralizing character of the early years of HIV. As the 1980s wore on, a hard- boiled fatalism settled in. Although patients and physicians did their best, they were all just playing out the same grim script… The growing sense of despair and frustration opened the door for charlatans.” Sepkowitz KA. N Engl J Med 2001; 344:1764-1772
Lessons ssons fr from m HIV IV/AI /AIDS DS • In the 1990s HAART available; fundamentally altered the epidemic Sepkowitz KA. N Engl J Med 2001; 344:1764-1772
Lessons ssons fr from m HIV IV/AI /AIDS DS • In the 1990s HAART available; fundamentally altered the epidemic • Sharp & sustained declines in mortality • Focus shifted to adherence, engagement in care Sepkowitz KA. N Engl J Med 2001; 344:1764-1772
Access & Adh dherence to o Lifesaving Med edic icatio ion Can an Fundamentall Fun lly Alter the the Ov Over erdose Ep Epid idemic ic Carrieri et al. Clinical Infectious Diseases, Volume 43, Issue Supplement_4, 15 December 2006, S197 – S215
De Deat aths hs Inc ncreas rease e Wh When en Me Medi dication ation St Stop opped ped Overdose Mortality 5 4.5 4 Rate per 1000 person years 3.5 3 2.5 2 1.5 1 0.5 0 In Treatment Out of Treatment Overdose Mortality 1.4 4.6 N=15 831 people treated with buprenorphine over 1.1-4.5 years (Sordo BMJ. 2017 Apr 26;357:j1550.)
What is is Effective Treatment? Psychosocial Interventions Medication Cognitive behavioral therapy Methadone Motivational enhancement Buprenorphine therapy Naltrexone Contingency management Recovery Supports Recovery coaching Mutual help organizations
Medication dication Tr Treatment atment Im Improves roves Retention, tention, Abstinence tinence, , Survival vival Buprenorphine Maintenance 75% retained in treatment 75% abstinent by toxicology Detoxification + counseling 0% retained in treatment 20% died Kakko et al. Lancet. 2003 Feb 22;361(9358):662-8
Go Goal al of of Me Medi dicatio ations ns for or Ad Addi diction tion Tr Trea eatme ment nt 1 2 3 4 Relieve Block effects Reduce Restore withdrawal of other cravings normal reward symptoms opioids pathway
Go Goal al of of Me Medi dicatio ations ns for or Ad Addi diction tion Tr Trea eatme ment nt Normal
Re Relap apse se Co Comm mmon on Af After er Ta Tape per Sigmon et al. JAMA Psychiatry. 2013;70(12):1347-1354.
Long Term rm Ou Outc tcomes: s: This is a Go Good Pro rognosis sis Dise sease se Engagement in agonist therapy associated with abstinence at Month 42: Patients still on agonist therapy: 79.6% abstinent Not on agonist therapy: 50.8% abstinent Weiss et al. Drug Alc Depend. 2015;150:112-9.
Early Use Duri ring Treatment Should be Expected Hser et al. Addiction. 2016 Apr;111(4):695-705.
Among ong Th Those se at t Hig ighest hest Ris isk k of Death, ath, Tr Treat eatment ment Retention tention Low • In 12 months after nonfatal overdose, 11% received MMT for median of 5 months, 17% bupe for median of 4 months, and 6% NTX for median of 1 month • Despite short duration of treatment, there was a reduction in all- cause mortality with MMT (AHR 0.47) and bupe (AHR 0.63). For NTX, there was no mortality benefit (AHR 1.44) Larochelle MR. Ann Intern Med. 2018 Aug 7;169(3):137-145.
Tr Treatment atment Retention tention Has s Benefit nefit Ir Irrespective espective of To f Toxicology icology Results sults • Treatment retention strongly associated with quality of life • Toxicology results not associated with QoL, however patient self- report of substance use was inversely related with QoL Mitchell SG. J Psychoactive Drugs. 2015 Apr-Jun;47(2):149-57
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