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OF THE PRESENTATION.
TODAY I'M VERY HONORED TO
PRESENT TODAY'S SPEAKER,
DR. ERIC C. STRAIN.
DR. STRAIN IS A GEORGE E BIGEOW
PROFESSOR IN THE DEPARTMENT OF
PSYCHIATRY AND BEHAVIORAL
SCIENCES AT JOHNS HOPKINS
UNIVERSITY SCHOOL OF MEDICINE.
THE DIRECTOR OF THE BEHAVIORAL
PHARMACOLOGY RESEARCH UNIT AT
HOPKINS, AND EXECUTIVE VICE
CHAIR FOR PSYCHIATRY AT THE BAY
VIEW MEDICAL CENTER.
DR. STRAIN COMPLETED HIS
BACHELOR OF ARTS AT AMHURST
COLLEGE IN MASSACHUSETTS AND
EARNED HIS MEDICAL DEGREE AT THE
OHIO STATE UNIVERSITY COLLEGE OF
MEDICINE.
HE COMPLETED HIS INTERNSHIP IN
MEDICINE AND PSYCHIATRY AT THE
FRANCIS SCOTT KEY MEDICAL
CENTER, PSYCHIATRY AT THE JOHNS
HOPKINS HOSPITAL.
FOLLOWING SERVICE AS CHIEF
RESIDENT, HE COMPLETED A
FELLOWSHIP IN A BEHAVIORAL
FELLOWSHIP PHARMACOLOGY RESEARCH
UNIT AT HOPKINS, NOW DIRECTOR.
DR. STRAIN IS A PROLIFIC
PHYSICIAN SCIENTIST IN SUBSTANCE
USE RELATED ISSUE, PROVIDING
CLINICAL CARE TO PATIENTS, TEA
TEACHING TO RESIDENTS AND
FELLOWS, AND DEVELOPING NEW
SUBSTANCE USE DISORDER
INITIATIVES AT HOPKINS.
DR. STRAIN'S AREAS OF RESEARCH
INCLUDE INVESTIGATING THE
OPTIMAL MECHANISM FOR TREATING
PATIENTS WITH SUBSTANCE USE
DISORDERS, THE RELATIONSHIP
BETWEEN SUBSTANCE USE AND OTHER
PSYCHIATRIC DISORDERS, THE
ABUTTE LIABABUSELIABILITY OF NOS
AT NEW NOVEL THERAPIES FOR
SUBSTANCE USE TREATMENT.
HIS STUDIES INCLUDE
BUPRENORPHINE, METHADONE,
PHARMACOTHERAPY FOR ALCOHOL
DEPENDENCE, AND
NON-PHARMACOLOGICAL THERAPIES
FOR SUBSTANCE USE DISORDERS.
DR. STRAIN IS A FORMER
EDITOR-IN-CHIEF FOR THE PEER
REVIEWED SCIENTIFIC JOURNAL DRUG
AND ALCOHOL DEPENDENCE.
HE CO-EDITED TEXTBOOKS,
METHADONE TREATMENT FOR OPIOID
DEPENDENCE, THE TREATMENT OF
OPIOID DEPENDENCE AND FIFTH
EDITION OF THE SUBSTANCE USE
COMPREHENSIVE TEXTBOOK.
DR. STRAIN WAS A LEAD IN
DEVELOPING THE FIRST
BUPRENORPHINE CURRICULUM, WHICH
WAS SUBSEQUENTLY USED AS A
PRIMARY SOURCE TO TRAIN
PHYSICIANS IN THE USES OF
MEDICATION FOR TREATMENT OF
OPIOID DEPENDENCE.
DR. STRAIN HAS SERVED AS CHAIR
OF THE FDA'S DRUG ABUSE ADVISORY
COMMITTEE, THE NIH ADDICTION
RISK AND MECHANISM STUDY
SECTION, AND THE AMERICAN
PSYCHIATRIC ASSOCIATION COUNCIL
ON ADDICTION PSYCHIATRY.
HE HAS SERVED AS PAST PRESIDENT
AND A BOARD MEMBER ON THE
COLLEGE ON PROBLEMS OF DRUG
DEPENDENCE AND HAS ALSO SERVED
ON VARIOUS COMMITTEES FOR
NATIONAL INSTITUTE ON DRUG
ABUSE, NATIONAL INSTITUTE ON
ALCOHOL ABUSE AND ALCOHOLISM,
AND FEDERAL TREATMENT SUBSTANCE
USE ATREATMENT.
THE TITLE OF HIS PRESENTATION
TODAY IS OPIOID USE DISORDER.
PLEASE WELCOME -- JOIN ME IN
WELCOMING DR. STRAIN.
[APPLAUSE]
>> THANK YOU.
AND THANKS FOR THAT KIND
INTRODUCTION, AND FOR INVITING
ME HERE TODAY TO TALK TO YOU
ABOUT SUBSTANCE USE, AND IN
PARTICULAR, OPIOID USE DISORDER.
I'VE TITLED THIS TALK, WHERE WE
WERE, WHERE WE ARE, AND WHERE WE
NEED TO GO.
AND I WILL TRY TO MOVE BRISKLY
THROUGH THESE SLIDES.
SO IN THE PAST 24 MONTHS, I'VE
HAD THE FOLLOWING RELATIONSHIPS,
YOU CAN SEE, AND THERE WILL BE A
DISCUSSION OF UNAPPROVED USES OF
MEDICATIONS IN MY TALK TODAY.
AND BY THE END OF THIS
PRESENTATION, YOU SHOULD BE ABLE
TO DISCUSS THE RELATIVELY RECENT
HISTORICAL CIRCUMSTANCES THAT
RESULTED IN INCREASED USE OF
OPIOIDS, IDENTIFY THE CAUSE OF
DIFFERENT WAVES OF OPIOID
OVERDOSE DEATHS AND LIST AT
LEAST THREE FDA-APPROVED
MEDICATIONS USED TO TREAT OPIOID
USE DISORDER.
SO LET'S GET TO IT.
HOW DID WE GET TO THE CURRENT
OPIOID PREDICAMENT?
AND OPIOID DRUGS, JUST TO REMIND
YOU, THEY MOSTLY ARE ANALGESICS,
THEY SUPPRESS COUGH, CONS TI COI
PAIT, THEY GENERAL CAN BE
ABUSED.
OXYCODONE, PERCOCET, TRAMADOL,
HYDROMORPHONE, HEROIN, FENTANYL
IS JUST A PARTIAL LIST OF THE
OPOPIOIDS.
JUST TO REMIND YOU, HEROIN WAS
DEVELOPED BY BAYER
PHARMACEUTICAL PRODUCTS AND WAS
ACTUALLY AN OVER THE COUNTER
MEDICATION AT THE TIME.
AND THEY ARE USEFUL MEDICATIONS
WHEN TAKEN PROPERLY.
SO LET'S NOT THROW OUT THE BABY
WITH THE BATHWATER.
AS WE THICK ABOUT THAT.
THINK ABOUT THAT, THE USE
OF THESE DRUGS.
SO I WANT TO TAKE A LITTLE
TANGENT, THOUGH, WHEN TALKING
ABOUT OPIOIDS, AND TALK A LITTLE
BIT ABOUT WHY DO PEOPLE USE AND
MISUSE DRUGS.
AND IN ORDER TO GET THERE, I
WANT TO THINK ABOUT HOW SOME
PEOPLE BUT NOT ALL, CERTAIN
DRUGS CAN PRODUCE A PLEASURABLE
EFFECT.
SO NOT EVERYBODY FINDS DRUSS
PRESSURABLE AND PARTICULAR DRUGS
PLEASURABLE.
JUST BECAUSE A DRUG PRODUCES A
PLEASURABLE EFFECT DOESN'T MEAN
A PERSON WILL MISUSE IT.
WE USE AND MISUSE DRUGS FOR
COMPLICATED REASONS.
AND I THINK ONE OF THE THINGS WE
STRUGGLE WITH IS THAT WE WANT TO
SIMPLIFY DRUG ABUSE AND WHY
PEOPLE USE DRUGS, BUT IT ISN'T
ALWAYS SIMPLE.
SO AS YOU THINK ABOUT DRUG
ABUSE, THINK ABOUT WHY DO WE
DRINK CAFFEINE?
BECAUSE PROBABLY SOMEWHERE
BETWEEN 70 AND 80% OF YOU USE
CAFFEINE ON A REGULAR BASIS,
RIGHT?
AND YOU KNOW, I USED TO SHOW
THIS SLIDE BECAUSE PEOPLE WOULD
SAY TO ME, I DON'T LIKE TO SEE
THAT LINE IN A METHADONE CLINIC
WHEN PEOPLE LINE UP TO GET THEIR
METHADONE, AND I'D SAY, WELL,
WHAT ABOUT THE LINE AT STARBU
STARBUCKS, TO GET THEIR
STARBUCKS CAFFEINE, RIGHT?
WE USE KA FEEP FOR COMPLICATED
REASONS.
AND I'M AS GUILTY AS ANYBODY FOR
USING CAFFEINE.
SO WHY DO WE DRINK CAFFEINE?
WHY DO WE USE A PSYCHOACTIVE
SUBSTANCE REGULARLY?
WELL, TAKING A SUBSTANCE AND
ENGAGING IN AN ACTIVITY HAS
ASPECTS OUTSIDE US AND INSIDE US
THAT CAN INFLUENCE USE.
AND I WANT TO TALK FIRST ABOUT
WHAT'S OUTSIDE US, AND WHAT'S
INSIDE US THEN THAT CAN
INFLUENCE USE.
I'M GOING TO TALK ABOUT ONE OF
MY FAVORITE ACTIVITIES AS AN
EXAMPLE OF THIS.
WHICH IS, EATING PIE.
OKAY?
I LIKE PIE.
AND I LIKE APPLE PIE, THIS IS AN
APPLE PIE, AND THIS IS -- THIS
LATTICE WORK KIND OF PIE IS THE
APPLE PIE MY MOTHER WOULD MAKE
EVERY THANKSGIVING.
AND I LOVED HER PIE.
I DIDN'T JUST LOVE HER APPLE
PIE, I LOVED HER APPLE PIE WITH
VANILLA ICE CREAM AND I WANTED
TWO SCOOPS OF T OF VANILLA ICE .
CREAM.
MY MOTHER WOULD MAKE A GREAT
TURKEY AT THANKSGIVING TIME WITH
DRESSING AND GREEN BEANS AND
SLICED ALMONDS AND ALL THAT GOOD
STUFF, THE SLICED ALMONDS IN THE
GREEN BEANS AND GRAVY, AND I
WOULD EAT THAT STUFF, AND MY
FAMILY WOULD EAT IT, AND THEN MY
MOTHER WOULD BRING OUT -- I'D BE
SATIATED, AND MY MOTHER WOULD
BRING OUT APPLE PIE AND SAY WHO
WANT APPLE PIE?
WHO WANTS APPLE PIE WITH VANILLA
ICE CREAM?
I WOULD SAY I WOULD.
NOW WHY IS THAT?
I WASN'T NEEDING CALORIES.
MY BODY WAS SAYING, YOU'VE GOT
ENOUGH CALORIES, ERIC.
YOU DON'T NEED MORE.
BUT I TOOK IT.
BECAUSE I HAD AN EXTERNAL QUEUE
THAT PROMPTED ME TO WANT TO
ENGAGE IN THE BEHAVIOR OF
EATING, EVEN THOUGH I WASN'T
HUNGRY.
RIGHT?
AND PROBABLY SOME OF YOU SITTING
HERE RIGHT NOW ARE THINKING, I'D
LIKE A SLICE OF PIE, RIGHT?
SO PIE AND ICE CREAM ARE QUEUES
THAT ARE OUTSIDE US THAT PROMPT
US TO WANT TO ENGAGE IN THE
BEHAVIOR OF EATING.
BUT WE ALSO HAVE THINGS INSIDE
US THAT DRIVE US TO EAT, THAT
CAN INFLUENCE USE.
AND YOU PROBABLY KNOW, WELL,
THAT THERE'S BEEN STUDIES THAT
WERE DONE DECADES AGO WHERE
LESIONING THE HYPOTHALAMUS IN
PARTICULAR IN RATS WOULD ENGAGE
THEM TO INCREASE OR DECREASE
EATING BEHAVIOR.
SO LATERAL HYPOTHALAMIC KNEW
CLIE EYE, LESIONING THOSE WOULD
RESULT IN DECREASED EATING.
THE MEDIAL HYPOTHALAMUS WOULD
INCREASE EATING IN RATS.
SO CLEARLY, AND THERE'S BEEN A
LOT OF OTHER STUDIES SINCE THEN
LOOKING AT THE HORMONAL EFFECTS
THAT PRODUCE US TO ENGAGE IN
INCREASED EATING OR DECREASED
EATING AS A BEHAVIOR, REGARDLESS
OF WHAT THE CALORIC NEED IS.
SO EATING, ENGAGING IN A
GOAL-DIRECTED ACTIVITY, CAN
OCCUR BECAUSE OF THINGS GOING ON
INSIDE US, FOR EXAMPLE, OUR BODY
SENDS PHYSIOLOGIC MESSAGES THAT
WE'RE HUNGRY.
AND IT CAN OCCUR BECAUSE OF
THINGS OUTSIDE OF US.
WE AREN'T NECESSARILY HUNGRY,
BUT CUES PROMPT US TO WANT TO
EAT.
AND JUST LIKE EATING, ENGAGING
IN THE BEHAVIOR OF TAKING A
SUBSTANCE LIKEWISE CAN BE
GOVERNED BY THINGS INSIDE US AND
OUTSIDE US.
THE CUES OF SEEING A STARBUCKS
OR WAKING UP IN THE MORNING AND
FEELING LIKE YOU NEED TO GET A
CUP OF COFFEE TO GET STARTED.
SO LIKE EATING, SUBSTANCE USE IS
AN ACTIVITY THAT CAN BE DRIVEN
BY THE THINGS THAT GO ON INSIDE
THE PERSON AND THINGS THAT CAN
GO ON OUTSIDE THAT PERSON.
IN PART, THAT'S WHAT MAKES IT
DIFFICULT AND COMPLICATED TO
TREAT.
PEOPLE WANT SIMPLE SOLUTIONS TO
TREATING A PERSON WITH SUBSTANCE
USE.
WELL, WE'LL COME BACK TO THIS,
LET'S JUST GIVE THEM
BUPRENORPHINE AND EVERYTHING
WILL BE OKAY.
AND SO OFTEN WE FIND THAT GIVING
BUPRENORPHINE OR METHADONE OR
SOME OTHER MEDICINE DOESN'T
SIMPLY SOLVE THE PROBLEM FOR A
PERSON WHO'S STRUGGLING WITH A
SUBSTANCE USE DISORDER.
SO WE CAN UNDERSTAND DRUG MISUSE
WHEN WE APPRECIATE OUR OWN
DRIVEN BEHAVIORS, I WOULD ARGUE.
WE DON'T HAVE TO AGREE WITH IT,
BUT WE CAN BEGIN TO UNDERSTAND
IT.
SO JUST AS WE MIGHT START TO
UNDERSTAND IF YOU TRY GOING
WITHOUT CAFFEINE FOR A WEEK, HOW
DOES THAT GO, OR IF YOU GO
WITHOUT SOMETHING ELSE FOR A
PERIOD OF TIME TO SEE HOW THAT
INFLUENCES YOUR BEHAVIOR.
SO I, FOR EXAMPLE, HAVE THIS
RECURRING NEW YEAR'S RESOLUTION,
WHICH JUST STARTEED 72 HOURS AG,
THAT I WILL NOT EAT SWEETS,
OKAY?
BECAUSE I LOVE SWEETS.
OBVIOUSLY, I LOVE PIE AND ICE
CREAM, YOU'VE ALREADY FOUND THAT
OUT, RIGHT?
SO -- AND IT BECOMES VERY
INTERESTING TO SEE ALL THE CUES
IN THE ENVIRONMENT, ALL THE
THINGS THAT GO ON, AND I'VE
TRIED THIS FOR YEARS.
I USUALLY TRY TO MAKE TO
THANKSGIVING.
AND I DID A ONE-YEAR AND IN THE
SUMMERTIME I WAS GIVING GRAND
ROUNDS IN RICHMOND, AND A FRIEND
TOOK ME TO LUNCH AND HE SAID,
OH, WE'VE GOT TO HAVE ICE CREAM
AT THE END OF LUNCH, THEY'VE GOT
GREAT ICE CREAM HERE.
I SAID I'M OKAY.
HE SAID NO, NO, YOU NEED TO TRY
IT.
I SAID, WELL, I'M OKAY, I
ACTUALLY MADE THIS NEW YEAR'S
RESOLUTION AND I'M TRYING NOT
TO.
THEN HE SAID, JUST HAVE A LITTLE
BIT.
IT WON'T COUNT.
[LAUGHTER]
RIGHT?
THAT SOUNDS JUST LIKE, YOU KNOW,
A DRUG DEALER WITH A DRUG
ABUSER.
JUST -- JUST -- JUST TAKE A
LITTLE BIT.
IT WON'T COUNT, RIGHT?
I DIDN'T TAKE ANY.
OKAY.
AND THEN EVERYONE HAS AN OPINION
ABOUT DRUG ABUSE.
I JUST WANT TO MAKE THAT POINT.
EVERYBODY DOES.
I REMEMBER ONCE YEARS AGO, MY
DENTIST WAS WORKING IN MY MOUTH
AND STARTED GIVING ME HIS
OPINION ABOUT DRUG ABUSE AND HOW
TO SOLVE IT, AND I AGREED WITH
EVERYTHING HE SAID BECAUSE HE
HAD SHARP INSTRUMENTS IN MY
MOUTH.
BUT EVERYBODY'S GOT AN OPINION.
SO HOW DID WE GET HERE WITH
OPIOID USE?
WELL, DOCTORS WERE BEING TOLD
THEY WERE UNDERTREATING PAIN.
WE WERE TOLD WE WERE WORRIED TOO
MUCH ABOUT ADDICTION, THERE WAS
A LOW RISK OF IT.
THERE WAS THIS FAMOUS LETTER TO
THE EDITOR IN THE NEW ENGLAND
JOURNAL OF MEDICINE IN 1980,
PORTER INJEK, IF YOU HAVEN'T
HEARD OF IT, YOU WILL AT SOME
POINT PROBABLY COME ACROSS IT
THAT WAS WIDELY CITED BY THE
PHARMACEUTICAL COMPANY INDUSTRY.
THEY SAID THEY DID THIS REVIEW
WITH 11,882 PATIENTS WHO
RECEIVED AT LEAST ONE NARCOTIC
PREPARATION AND FOUND ONLY FOUR
CASES OF WELL DOCUMENTED
ADDICTION IN PATIENTS WHO HAD NO
HISTORY OF ADDICTION.
AND EVERYBODY SAID, LOOK, GIVE
PEOPLE OPIOIDS.
PEOPLE DON'T GET ADDICTED WITH
OPIOIDS.
SO THEN DOCTORS WERE BEING TOLD
WE WERE UNDERTREATING PAIN AND
WE WERE LETTING PATIENTS SUFFER
WITH PAIN, WAS THE OTHER THING.
AND IF YOU LIVE THROUGH THIS,
YOU KNOW IN 1995, THE MIRN PAIN
SOCIETY PUT OUT PAIN AS A FIFTH
VITAL SIGN.
IN 1998, AND THEN AGAIN IN 2004,
THE FEDERATION OF STATE MEDICAL
BOARDS POLICIES ESSENTIALLY
ENCOURAGED DOCTORS TO PRESCRIBE
OPIOIDS FOR PAIN.
THE JOINT COMMISSION ENCOURAGES
TREAT OF PAIN OF THEY WANT TO
SEE DOCUMENTATION OF THAT FIFTH
VITAL SIGN.
THERE'S JUST A CONFLUENCE COMING
ABOUT WHERE WE'RE NOT TREATING
PAIN ADEQUATELY.
AND, OF COURSE, THERE'S
AGGRESSIVE MARKETING OF OPIOID
ANALGESIC MEDICATIONS, RIGHT?
SO I THINK EVERYBODY AT THIS
POINT HAS HEARD ABOUT OXYCONTIN
AND OXYCODONE IS THE OPIOID IN
OXYCONTIN, IT'S MARKETED BY
PURDUE STARTING IN 1996.
IT'S NOT PARTICULARLY SUPERIOR
TO OTHER ANALGESICS, BUT IT'S
GOT A LONGER DURATION OF ACTION
VERSUS OTHER OXYCODONE PRODUCTS,
IT WORKS FOR 12 HOURS.
THEY DO A MAJOR MARKETING PUSH
BY PURDUE PHARMACEUTICALS, SO
YOU HAVE THINGS LIKE DOCTORS
GETTING THESE CLOCKS SHOWING
THAT IT WORKS FOR 12 HOURS,
HATS.
THERE WAS A CD, GET IN THE SWING
WITH OXYCONTIN, THERE WERE TOYS,
TEDDY BEARS, DINNERS FOR
PHYSICIANS, ALL SORTS OF THINGS
PUSHING TO GET DOCTORS TO
PRESCRIBE MORE OXYCONTIN.
THIS JUST SHOWS OXYCONTIN SALES.
THEY REACHED $3 BILLION IN 2010.
AND CONTINUE TO BE HIGH.
I THINK MOST PEOPLE ARE FAMILIAR
WITH THIS STORY, THE SACHLER
FAMILY, PURDUE FA PHARMACEUTICAS
WAS A PRIVATELY HELD COMPANY,
THE SACHLERS OWNED, AND IT'S A
BLOCKBUSTER DRUG DESPITE THE
BACKLASH THAT OCCURRED.
IT IMPORTANT TO NOTE THAT IT
WASN'T JUST OXYCONTIN.
OXYCONTIN AND OTHER OPIOID
ANALGESICS DON'T WRITE THEIR OWN
PRESCRIPTIONS.
IT WAS A CULTURAL PHENOMENON IN
MEDICINE AND IN THE BROADER
SOCIETY THAT SUGGESTED THAT WE
NEEDED TO BE MORE AGGRESSIVE
ABOUT MARKETING.
OPIOID DRUGS.
SO WHERE ARE WE NOW WITH OPIATE
USE WITH THAT SORT OF BACKGR
BACKGROUND?
SO THESE -- I'M GOING TO HAVE A
FEW SLIDES OF THIS.
THIS SHOWS OPIATE PRESCRIPTIONS
DISPENSED, AND IT SHOWS A
BREAKOUT OF -- THE RED LINE IS
HYDROCODONE, THE GREEN LINE IS
OXYCODONE.
SO YOU SEE HERE, AND YOU SEE
THAT STARTING AROUND 2010 TO
2012 AND INTO 2013, WE START TO
SEE AS THIS BACKLASH OCCURS, WE
START TO SEE A DECREASE, SOME
DECREASE IN PRESCRIBING OF
OPIATE ANALGESICS.
AND THIS IS A DIFFERENT SLIDE
THAT LOOKS AT OPIATE
PRESCRIPTIONS DISPENSED FROM A
DIFFERENT DATASET, AND YOU SEE
THIS GOES TO 2020, AND YOU SEE
CLEARLY THAT PRESCRIPTIONS ARE
DECLINING HERE PRETTY
DRAMATICALLY BY 2020.
SO IT GOES FROM A HIGH OF A
LITTLE OVER 250 MILLION DOWN TO
LESS THAN 150 MILLION IN THE
SPACE OF LESS THAN 10 YEARS.
SO OF COURSE ANOTHER PROBLEM,
THOUGH, NOT JUST IN OPIATE
PRESCRIPTIONS BUT WHAT REALLY
CAPTURES US IS OPIATE OVERDOSE
DEATHS FROM THE USE OF OPIOIDS.
AND I THINK, AGAIN, THIS IS
REAL --THIS HAS REALLY NOW BEENL
DISSEMINATED INTO THE COMMUNITY.
I WANT TO HIGHLIGHT FOR YOU THAT
THERE WERE FOUR OVERLAPPING
WAVES OF OPIATE OVERDOSE DEATHS.
SO THE FIRST WAVE BEGINS, AND
I'LL SHOW THIS TO YOU
GRAPHICALLY IN A MOMENT, IN THE
1990s WITH THE LIBERAL
PRESCRIPTION OF OPIOIDS, SO WHAT
WE JUST TALKED ABOUT WITH
RESPECT TO OXYCONTIN AND OTHER
OPIOIDS AS WELL, THEN AS THOSE
START TO DECREASE, WE SEE A
SHIFT OVER TO HEROIN USE, WHICH
STARTS AROUND 2010, SO AS WE
CONTRACT THE AVAILABILITY OF
PRESCRIPTION OPIOIDS, WE SEE
PEOPLE SHIFTING OVER TO HEROIN.
THEN AROUND 2013, THERE'S A
PRETTY QUICK SHIFT FROM HEROIN
TO FENTANYL AND FENTANYL ANALOGS
LIKE CARFENTANYL.
AND NOW MOST RECENTLY, AROUND
2015, WE SEE THAT IT'S OPIOIDS
WITH OTHER DRUGS AND IN
PARTICULAR STIMULANTS AND
XYLAZINE.
I'M NOT GOING TO TALK A LOT
ABOUT THESE TODAY, BUT I WILL
COME BACK TO STIMULANTS IN
PARTICULAR IN A MINUTE.
BUT THIS IS REALLY -- HAS REALLY
WHERE WE'VE BEEN CURRENTLY.
THIS IS A PAPER THAT ONE OF OUR
FACULTY MEMBERS REVIEWED, SHE
PUBLISHED IN THE AMERICAN
JOURNAL OF PSYCHIATRY, I WAS
GOING TO SAY LAST YEAR BUT IT'S
NOW TWO YEARS AGO.
, OF DRUG
OVERDOSE DEATHS FROM 2016 TO
2021 BY DRUG TOXICOLOGY REPORTS.
WHAT YOU SEE HERE IS FOR ANYBODY
OPIOID OVERDOSE, THERE WERE OVER
80,000 DEATHS IN 2021, LAST YEAR
THAT DATA WERE AVAILABLE.
THAT SYNTHETIC OPIOIDS EXCLUDING
METHADONE, SO THAT'S ESSENTIALLY
FENTANYL AND FENTANYL AN LOGS,
ARE THE OVERWHELMING MAJORITY AS
THIS POINT OF THOSE DEATHS.
YOU SEE, ON THE OTHER HAND,
HEROIN IS A VERY SMALL
PROPORTION, IT'S NOT SOMETHING
THAT SHOULD JUST BE IGNORED BUT
IT'S LESS THAN 10,000 DEATHS.
AND IF YOU LOOK AT THAT, IT'S
REALLY BEEN PRETTY LOW AND FLAT
OVER TIME, THOSE DEATHS FROM
HEROIN.
AND THEN NATURAL SEMI SYNTHETIC
OPIOIDS, THINGS LIKE OXYCODONE,
OXYCONTIN, MORPHONE, THOSE ARE
RELATIVELY FLAT AS WELL AT ABOUT
13,000 DEATHS.
SO REALLY IT'S THESE, YOU
KNOW -- THE BIG THING IS THIS
70,000 THE FENTANYL AND FENTANYL
ANALOGS AT THIS POINT THAT'S
REALLY TAKEN OFF IN THIS FOURTH
WAVE, THIRD TO FOURTH WAVE OF
OVERDOSE DEATHS.
WHILE I'M NOT GOING TO FOCUS ON
IT TODAY, I DO WANT TO HIGHLIGHT
THAT THERE'S INCREASING RATES OF
STIMULANT MISUSE AND ASSOCIATION
WITH OVERDOSE DEATHS.
SO GOING BACK TO THAT FIGURE,
LOOK AT THIS GREEN LINE, WHICH
IS STIMULANTS, WHICH IS
METHAMPHETAMINE, COCAINE, WHICH
IS REALLY -- HAS REALLY BEEN
GOING UPWARDS NOW.
THIS IS TYPICALLY COMBINED WITH
OPIOIDS, BUT STILL IT'S A
PROBLEM AND A CONCERN THAT WE
NEED TO BE AWARE.
THESE ARE -- I THOUGHT ABOUT
TAKING THIS OUT BECAUSE THIS IS
A PAPER THAT CAME OUT IN 2015 BY
CASE AND DEITIN, THERE'S BEEN
SOME PUSHBACK ABOUT WHETHER THE
ANALYSES ARE CORRECT BUT I STILL
THINK IT'S WORTH SHOWING.
THIS IS -- THEY SHOWED U.S.
DEATH RATE - IN 45 TO 45 TO
54-YEAR-OLDS, THESE ARE DEATHS
PER 100,000.
THESE ARE DIFFERENT COUNTRIES
THAT ARE SHOWN, SO YOU CAN SORT
OF FIGURE IT OUT.
THIS IS FRANCE, GERMANY, THE
U.K., CANADA, AUSTRALIA, SWEDEN.
AND WHAT YOU SEE OVERALL IS THAT
THE LINES ARE ALL KIND OF
TRENDING DOWN OVER TIME IN DEATH
RATES, WITH THE EXCEPTION OF
U.S. WHITE NON-HISPANICS.
AND AGAIN, THERE'S BEEN SOME
PUSHBACK ABOUT THESE ANALYSES,
BUT I THINK IT STILL HAS BEEN
SOMETHING THAT'S CAPTURED A LOT
OF ATTENTION BECAUSE IT DOES
SEEM LIKE IT'S A PARTICULAR
POPULATION THAT'S BEEN A
CONCERN.
SO IT'S A RELATIVELY FLAT DEATH
RATE COMPARED TO OTHERS, AND
THIS OBVIOUSLY PRECEDES COVID.
INTERESTINGLY, THAT U.S. H IS
U.S. HISPANICS, AND THAT LINE
HAS STILL BEEN TRENDING DOWN
LIKE OTHER COUNTRIES OVER THIS
TIME PERIOD.
SO IT WASN'T SIMPLY THE WHOLE
POPULATION, THIS HAS REALLY HIT
U.S. WHITES, IT'S BEEN NOTED.
IF YOU'RE INTERESTED IN READING
ABOUT THIS, THERE'S TALK ABOUT
SAM KIONE'S BOOKS, IN
PARTICULAR, DREAMLAND AND THE
LEAST OF US, I WOULD RECOMMEND.
I THINK -- THE LEAST OF US, I
HOPE SAM ISN'T LISTENING IN, BUT
I THINK THE LEAST OF US IS A
BETTER VERSION OF DREAMLAND.
IT'S KIND OF LIKE HE WROTE THE
SAME BOOK TWICE AND HE GOT A
LITTLE BIT BETTER THE SECOND
TIME.
BUT THEY'RE BOTH GOOD BOOKS.
TALKING ABOUT SORT OF THE
EPIDEMIOLOGY OF OPIOID ABUSE, I
THOUGHT THIS WAS AN INTERESTING
PAPER I WANT TO HIGHLIGHT ABOUT
WHERE DO PEOPLE GET OPIOIDS AND
ESPECIALLY PRESCRIPTION OPIOIDS.
THESE DATA ARE OLD NOW, ALMOST
10 YEARS OLD.
BUT I THINK THEY'RE INTERESTING.
IT VARIES AS A FUNCTION OF
WHETHER THEY HAVE PROBLEMATIC
USE OF PRESCRIPTION OPIOIDS.
SO THIS IS A PAPER THAT WAS
PUBLISHED NOW ABOUT SEVEN YEARS
AGO BY HANN, ET AL. IN THE
ANNALS OF INTERNAL MEDICINE.
THEY USED NSDA DATA, THE
NATIONAL SURVEY ON DRUG USE AND
HEALTH FROM 2015, AND THIS WAS,
I THOUGHT, A VERY INTERESTING
PAPER.
THEY SHOWED ADULTS WHO WERE
REPORTING MISUSE WITHOUT A USE
DISORDER, SO THESE ARE PEOPLE
WHO ARE SORT OF SPORADICALLY
USING BUT THEN NOT DEVELOPING
PROBLEMATIC USE, AND COMPARED
THAT TO ADULTS REPORTING A USE
DISORDER, SO BASICALLY WHAT WE
USED TO CALL DEPENDENCE OR ABUSE
ON OPIOIDS.
WHAT YOU SEE IS THAT IF YOU
DIDN'T HAVE A USE DISORDER,
YOU'D OBTAINED OPIOIDS FOR FREE
FROM A FRIEND OR RELATIVE, MORE
COMMONLY.
SO THIS IS SORT OF -- I GO CLEAN
MY GUTTERS, I M COULD IN, MY
BACK HURTS, I ASK MY WIFE IF SHE
STILL HAS, YOU KNOW, A DILAUDID
FROM WHEN SHE HAD HER TOOTH
TAKEN OUT AND I TAKE IT.
IT'S THAT SORT OF THING.
AND I DON'T -- I'VE NEVER DONE
THAT, BY THE WAY, FOR THE
RECORD.
IS THIS BEING RECORDED?
YEAH, I'VE NEVER DONE THAT, BUT
THAT WOULD BE AN EXAMPLE OF WHAT
HAPPENS.
ON THE OTHER HAND, FOR PEOPLE
WHO HAVE A USE DISORDER, THEY'RE
BUYING THEM FROM A FRIEND OR
RELATIVE, MORE COMMONLY, SO
THEY'RE BUYING THEM, OR THEY'RE
BUYING THEM FROM OTHERS, FROM A
DRUG DEALER OR A STRANGER.
OKAY.
SO WHERE ARE WE NOW WITH OPIATE
ABUSE?
TO SUMMARIZE, IT'S A CHANGING
LANDSCAPE.
WHERE WE ARE NOW IS NOT WHERE WE
WERE JUST A FEW YEARS AGO.
WE'RE SEEING A CLEAR DECREASE IN
THE PRESCRIBING OF OPIOIDS, SO
PHYSICIANS HAVE GOT THE MESSAGE
THEY WERE OVERPRESCRIBING
OPIOIDS, THEY WERE TOO LIBERAL,
THERE'S BEEN A LOT OF PUSHBACK
ON THAT.
THERE'S BEEN A LOT OF WORK WITH
ELECTRONIC MEDICAL RECORDS AND
THINGS LIKE THAT TO GET
PHYSICIANS TO DECREASE THEIR
PRESCRIBING OF OPIOIDS.
HEAR WIN USHEROIN USE IS LEVELIR
DECREASING, THAT IS HEROIN, NOT
FENTANYL.
AND LET ME SAY THERE, IT'S
INTERESTING BECAUSE WHEN I TALK
TO PEOPLE ABOUT WHAT THEY'RE
USING, THEY'LL SAY, WELL, I'M
USING HEROIN.
AND THEN WE'LL TEST THEIR URINE,
AND IT DOESN'T HAVE ANYTHING
EVIDENCE OF MORPHINE IN IT,
WHICH IS THE METABOLITE FROM
HEROIN.
BUT IT HAS FENTANYL IN IT.
AND I'LL TELL THEM, YOU DIDN'T
USE HEROIN.
YOU USED FENTANYL.
AND THEY'LL SAY NO, NO, I
DIDN'T.
I BOUGHT HEROIN ON THE STREET.
I'M NOT USING FENTANYL.
SO EVEN THOUGH PEOPLE MAY BE
SAYING THEY'RE USING HEROIN,
WHAT THEY'RE REALLY USING IS
FENTANYL AT THIS POINT.
SO THERE'S INCREASING FENTANYL
MISUSE, AND WE'RE SEEING THE
ADDITION NOW OF SI XYLAZINE TO E
SUPPLY.
THERE'S INTERESTING STUFF COMING
OUT, IF YOU'RE NOT FAMILIAR WITH
XYLAZINE, THE STREET NAME IS
TRA NC.
WE'RE STARTING TO GO BACK AND
LOOK AT URINE SAMPLES IN TESTS
AND WE'RE SEEING THAT THERE'S
RAMPANT USE -- THERE'S
FREQUENTLY URINE SAMPLES
POSITIVE FOR FENTANYL AND
XYLAZINE.
WHICH IS PROBLEMATIC, WE'RE
FINDING.
AND I WANT TO SAY, WE MAY BE
PLAYING WHACK MOLE HERE.
WE ADDRESS ONE PROBLEM,
PRESCRIPTION OPIATE USE,
AANOTHER POPS UP, LIKE FENTANYL.
SO I THINK THAT WE NEED TO BE
CAREFUL THERE.
AS WE THINK ABOUT
THIS AND SAY GEE, WE DON'T HAVE
THE OPIOID PROBLEM UNDER CONTROL
BECAUSE WE GOT PRESCRIPTION
OPIATE USE DECREASING BUT WE'RE
JUST SHIFTING OVER TO SOMETHING
THAT'S ACTUALLY MORE PROBLEM
PROBLEMATIC.
SO NEXT I WANT TO TURN TO WHAT
CAN WE DO.
AND I'M GOING TO MAKE SOME
GENERAL POINTS ABOUT WHAT WE CAN
DO, THEN I'M GOING TO TALK ABOUT
CURRENT MODALITIES OF TREATMENT,
I'M GOING TO TALK A LITTLE ABOUT
FUTURE OR NEW TREATMENTS, AND
I'LL TAKE A MOMENT TO TALK ABOUT
CREATING INTEGRATED SYSTEMS OF
CARE.
I'VE BEEN THINKING ABOUT THAT A
LITTLE BIT IN TERMS OF SYSTEMS
RATHER THAN SIMPLY AT THE
PATIENT LEVEL.
OKAY.
SO LET'S TALK FIRST ABOUT SOME
GENERAL POINTS.
THE FIRST GENERAL POINT I WANT
TO MAKE IS, THE PROBLEM IS EASY
TO DEVELOP, BUT
OVERNITRIFICATIOOVERNIGHT FIXES.
I THINK THIS IS -- HOPEFULLY I'M
IN SHOUTING DISTANCE OF CONGRESS
AND THE WHITE HOUSE AND THINGS
STANDING HERE, BUT YOU KNOW, I
THINK PEOPLE, POLITICIANS, THE
LAY PUBLIC, THEY WANT ANSWERS
AND THEY WANT ANSWERS NOW.
I MET WITH A DONOR ABOUT THREE
OR FOUR YEARS AGO WHO WANTED TO
GIVE SOME MONEY, AND THEY WANTED
TO GO TO SOMETHING THAT WOULD
FIX OPIATE OVERDOSES WITHIN THE
NEXT YEAR.
YEAH.
YOU KNOW, AND I'VE MET WITH
LEADERSHIP OR HEALTH SYSTEMS AT
TIMES WHO WILL SAY WE WANT TO
DECREASE OPIATE OVERDOSE DEATHS
IN EAST BALTIMORE BY SOMETHING
LIKE 50% WITHIN THE NEXT YEAR.
IT'S SORT OF -- YOU KNOW, AND
IT'S JUST PORTRAYING THE NAIVETY
ABOUT HOW COMPLICATED THIS
DISORDER IS AND HOW DIFFICULT IT
IS TO TREAT IT.
AND THERE AREN'T
OVERNITRIFICATIONS.
OVER --OVERNIGHT FIXES.
OVERNIGHT FIXES ARE RARELY
AVAILABLE.
PEOPLE LOOK FOR MIRACLE CURES.
CANNABIS, HEROIN, PSYCHEDELICS.
THERE'S A FLAVOR THAT COMES
AROUND EVERY FIVE OR 10 YEARS.
I MEAN, RIGHT NOW IT'S SORT OF
KRATOM AND PSYCHEDELICS ARE THE
TWO BIGGIES.
PSYCHEDELICS ARE GOING TO CURE
EVERYTHING, TREATMENT-RESISTANT.
AND WE'RE A BIG RESEARCH SITE
FOR PSYCHEDELICS, OUR RESEARCH
GROUP.
DEPRESSION, PTSD, CANNABIS USE
DISORDER, LYME DISEASE,
ANOREXIA.
YOU KNOW, YOU CAN NAME SOMETHING
AND WE'LL TRY PSYCHEDELICS FOR
IT.
I THINK THEY CAN BE USEFUL, BUT
I THINK THEY'RE ANYWAY.
QUALITY TREATMENT WORKS.
WE NEED TO RECOGNIZE THE
COMPLEXITY OF DRUG USE, THE
PHYSICAL AS WELL AS THE
ENVIRONMENTAL CIRCUMSTANCES THAT
DRIVE USE, THOSE THINGS INSIDE
US, OUTSIDE US, QUALITY
TREATMENT WORKS.
QUALITY TREATMENT IS NOT
INEXPENSIVE.
WE NEED TO DECREASE THE NUMBER
DEVELOPING THE PROBLEM AND
PROVIDE TREATMENT TO THOSE WHO
HAVE IT.
SO WE NEED TO BOTH DECREASE --
TURN DOWN THE WATER THAT'S
COMING IN TO THE BATHTUB, WHILE
WE ALSO ADDRESS THE WATER THAT'S
IN THE BATHTUB AS WELL.
AND IF WE AREN'T DOING BOTH OF
THOSE THINGS, THEN WE'RE JUST
GOING TO CONTINUE TO BE IN THE
SAME SITUATION.
AND TREATMENT MAY TAKE TIME TO
WORK FOR SOMEONE.
THAT'S IMPORTANT.
SO THIS IS A SLIDE, A FIGURE
FROM A PAPER THAT SHUR PUBLISHED
15 OR MORE YEARS AGO NOW.
THIS IS KIND OF INTERESTING.
THEY LOOKED BACK AT THE LIFE
COURSE, THEY HAD DATA ON OVER 33
YEARS OF 471 MALE HEROIN USERS
IN THE CALIFORNIA AREA, AND WHAT
THEY FOUND, THIS IS DAYS USED,
AND THEY FOUND THAT PEOPLE SORT
OF FELL INTO THREE CATEGORIES.
SOME PEOPLE WITHIN A FEW YEARS
REALLY DECREASED AND THEN
STOPPED THEIR USE.
SOME PEOPLE, IT TOOK TIME, ABOUT
A THIRD, AND SOME PEOPLE JUST
KEPT USING.
BUT WE CAN'T GIVE UP, I THINK IS
THE POINT.
BECAUSE WE DON'T KNOW A YEAR
INTO IT WHICH OF THESE THREE
GROUPS SOMEBODY FALLS INTO, AND
WHO KNOWS, MAYBE THIS GROUP OF
YELLOW WILL START TO TREND DOWN.
SO WE CAN'T GIVE UP.
AND TREATMENT TAKES MULTIPLE
TRIALS OFTEN WITH OPIATE USE
DISORDER TO HAVE AN EFFECT.
SO TREATMENT VARIES.
THERE ARE SOME FOR WHOM IT'S
RELATIVELY EASY, BUT THERE IS A
POPULATION THAT'S MUCH MORE
PROBLEMATIC.
SO I'M GOING TO TALK ABOUT
BUPRENORPHINE IN A MINUTE
BRIEFLY, BUT I WANT TO
ACKNOWLEDGE, THERE ARE SOME
PEOPLE PRESCRIPTION OPIOID USERS
GOT PUT ON BUPRENORPHINE, THEY
HAD RELATIVELY STABLE LIVES,
THEY WORKED, THEY HAVE SOCIAL
SUPPORTS, THEY HAD GOOD
INSURANCE AND THEY'VE GONE ON
WITH THEIR LIVES AND THAT'S
GREAT.
BUT THERE ARE SOME PEOPLE WHO
DON'T -- YOU KNOW, IT'S MUCH
MORE COMPLICATED.
WHEN YOU LOOK AT THE DATA ON
BUPRENORPHINE AND PEOPLE GETTING
PLACED ON BUPRENORPHINE,
GENERALLY, THE OVERWHELMING
MAJORITY, SOMETHING LIKE 50% OR
MORE, DEPENDING UPON THE STUDY,
DROP OUT OF TREATMENT.
SO WE'VE GOT TO FIGURE OUT WHY
IS THAT, AND WHAT CAN WE DO TO
KEEP PEOPLE ENGAGED IN
TREATMENT.
BECAUSE SOME PEOPLE, IT JUST
DOESN'T TAKE RIGHT AWAY.
SO LET'S TALK ABOUT CURRENT
MODALITIES OF TREATMENT,
THINKING BROADLY.
SO MEDICATIONS, THERE ARE THREE
FDA-APPROVED MEDICATIONS FOR
WHAT WOULD BE CALLED
MEDICATION-ASSISTED TREATMENT,
MAT.
BUPRENORPHINE, METHADONE AND
NALTREXONE.
I'M JUST GOING TO TOUCH ON EACH
OF THESE.
BUPRENORPHINE, IT'S MARKETED AS
A TRANS MUCOSAL, SUBLINGUAL
TABLETS OR FILMS.
THERE'S ALSO LONG-ACTING
INJECTIONS THAT CAN BE GIVEN
EITHER WEEKLY OR MONTHLY.
THERE WAS A SIX-MONTH ROD THAT
WAS PUT UNDER THE SKIN, KIND OF
LIKE NORPLANT.
IT'S NOW OFF THE MARKET, BUT IT
WAS DEVELOPED AND WAS EFFECTIVE.
IT JUST DIDN'T GET MUCH UPTAKE.
BUPRENORPHINE IS EFFECTIVE, IT'S
AVAILABLE AS AN OFFICE-BASED
OPIOID TREATMENT OR THE ACRONYM
OFTEN USED IS OBOT.
THEY HAD TO GET A SPECIAL X
NUMBER.
YOU NO LONGER NEED TO GET AN X
NUMBER, A SPECIAL DEA NUMBER TO
PRESCRIBE IT.
IT'S PRETTY EASY TO PRESCRIBE
NOW IN MOST OF THE COUNTRY.
NEXT, METHADONE.
THIS IS AN ORAL DAILY DOSING
MEDICATION.
IT'S EFFECTIVE, IT'S GENERALLY A
MEDICATION THAT INCLUDES
NON-PHARMACOLOGIC TREATMENT,
COUNSELING SERVICES, GROUPS,
CONTINGENCY MANAGEMENT.
I'LL COME BACK TO SOME OF THOSE
IN A MINUTE.
IT'S ESSENTIALLY ONLY AVAILABLE
THROUGH A SPECIALIZED CLINIC
TREATMENT, OPIOID TREATMENT
PROGRAMS, OTPs IS THE FEDERAL
TERM FOR THAT.
THERE IS DISCUSSION ABOUT MOVING
METHADONE INTO OFFICE-BASED
PRACTICE LIKE BUPRENORPHINE IS
AND ALLOWING PEOPLE TO PRESCRIBE
IT.
AND THEN THE THIRD MEDICATION IS
NALTREXONE.
IT HAS ORAL DOSING.
IT CAN BE GIVEN EITHER DAILY OR
THRICE WEEKLY.
THERE ALSO IS A LONG-ACTING
INJECTABLE GIVEN ONCE A MONTH.
THERE CAN BE SOME DIFFICULTY TO
TRANSITION ONTO IT, BUT THE
EVIDENCE OF -- THERE IS EVIDENCE
OF GOOD EFFICACY WHEN YOU GET A
PATIENT ON NALTREXONE.
NIDA'S CLINICAL TRIALS NETWORK
PUBLISHED A NICE MULTI-SITE
STUDY OF THAT A FEW YEARS AGO.
THAT SHOWED THAT NALTREXONE
COULD BE QUITE EFFECTIVE ONCE
YOU GOT THROUGH THAT TRANSITION
PERIOD.
IN ADDITION TO MEDICATIONS,
THERE'S OBVIOUSLY
NON-PHARMACOLOGIC TREATMENTS,
AND THERE'S THINGS LIKE
INPATIENT SERVICES, RESIDENTIAL
PROGRAMS, OUTPATIENT COUNSELING,
SELF-HELP GROUPS SUCH AS
NARCOTICS ANONYMOUS.
THESE CAN ALL BE VERY HELPFUL.
AND THERE'S ALSO MODALITIES SUCH
AS CONTINGENCY MANAGEMENT,
SOMETIMES REFERRED TO AS CM,
MOTIVATIONAL INTERVIEWING AND
12-STEP FACILITATION.
I POINT OUT THAT MULTIPLE
REVIEWS HAVE SHOWN CON TINGE Z.
MANAGEMENT AS A HIGHLY EFFECTIVE
TREATMENT INTERVENTION.
AND I WANT TO JUST ACKNOWLEDGE
THERE ARE THINGS LIKE
PRESCRIPTION DRUG MONITORING
PROGRAMS WHICH HAVE BEEN VERY
USEFUL, I THINK, IN TERMS OF
GETTING CONTROL OF PRESCRIPTION
OPIOID USE.
THOSE REALLY HAVE COME ONLINE
NATIONALLY OVER THE LAST FEW
YEARS AND REALLY ARE ROBUST
SYSTEMS.
THERE ARE ALSO THINGS LIKE
OPIOID TREATMENT COMMUNITIES AND
HEALTH SYSTEMS THAT HAVE COME
TOGETHER TO FIGURE OUT HOW TO
BETTER MANAGE OPIATE USE
DISORDER, AND USE OF ELECTRONIC
MEDICAL RECORDS, EMRs, HAS
BEEN A HELPFUL STEP FORWARD AS
WELL TO GET CONTROL OF,
ESPECIALLY, AGAIN, PRESCRIPTION
OPIOID USE.
CURRENT TREATMENTS CAN WORK WELL
WHEN COMBINING MEDICATION WITH
NON-PHARMACOLOGIC TREATMENT,
ESPECIALLY CONTINGENCY
MANAGEMENT.
SO LET ME MOVE ON TO TALK A
LITTLE BIT ABOUT SOME KIND OF
FUTURE TREATMENTS OR THINGS TO
THINK ABOUT IN TERMS OF
TREATMENTS GOING FORWARD.
KIND OF -- WE'VE BEEN LOOKING
OUR SHOULDER WHAT'S AVAILABLE
OUT THERE, NOW LET'S LOOK AHEAD
TO THINK ABOUT WHAT'S AVAILABLE.
SO I WANT TO TALK ABOUT
MEDICATIONS AND DEVICES, AND I'M
GOING TO GO INTO A LITTLE BIT OF
DETAIL ON A COUPLE OF THESE.
THERE HAVE BEEN FURTHER DEVEL
DEVELOPMENT OF WAYS -- THAT'S A
TYPO, IT SHOULD SAY WAYS TO
OPTIMIZE USE OF LONG-ACTING
INJECTABLES LIKE BUPRENORPHINE
AND THE WEEKLY AND MONTHLY
PRESCRIBING OF THAT.
I THINK THAT THAT'S SOMETHING
THAT WE CAN BE THINKING ABOUT
FURTHER BECAUSE YOU CAN PUT
SOMEBODY ON WEEKLY LONG-ACTING
INJECTABLE BUPRENORPHINE RIGHT
AWAY.
YOU DON'T HAVE TO PUT THEM ON
SUBLINGUAL OR TRANS MUCOSAL
FIRST, SO THAT OPENS UP
OPPORTUNITIES TO THINK ABOUT
STARTING PEOPLE ON MEDICATIONS N
NOVEL SETTINGS, LIKE EMERGENCY
DEPARTMENTS.
THERE'S ALSO WITHDRAWAL
MEDICATIONS ON PARTICULAR
LOFEXIDINE, IT'S LIKE CLONIDINE
THAT CAN BE USED FOR WITHDRAWAL
OFF OF OPIOIDS AND IS RELATIVELY
UNDERUTILIZED, I THINK, AT THE
MOMENT.
THEN AS I MENTIONED A MOMENT
AGO, METHADONE THROUGH OFFICE
BASED OPIOID TREATMENT, THERE'S
BEEN NOT SOME, THERE'S BEEN A
LOT OF INTEREST IN TRYING TO
MOVE METHADONE OUT OF THE OPIOID
TREATMENT PROGRAMS OR THE OLD
WHAT WE CALL METHADONE CLINICS,
AND ALLOWING PHYSICIANS AND
OTHER PROVIDERS TO PRESCRIBE
METHADONE FOR OPIOID DEPENDENCE
OUT OF OFFICE-BASED PRACTICES.
ONE OF THE THINGS WE'VE GOTTEN
INTERESTED IN IS WITHDRAWAL
DEVICE.
THERE ARE TWO.
ONE IS CALLED THE BRIDGE DEVICE
AND THERE'S ANOTHER CALLED THE
SPARROW ASCENT.
THESE ARE KIND OF INTERESTING
DEVICES.
I CONFESS I WAS NOT REALLY AWARE
OF DEVICES AND THE FDA APPROACH
TO DEVICES AS MUCH AS I PROBABLY
SHOULD HAVE BEEN BEFORE THIS.
THE BRIDGE DEVICE, AND HERE'S A
PICTURE OF IT, IS WORN FOUR TO
FIVE DAYS, IT STIMULATES CRANIAL
NERVES WITH ENDINGS IN THE EAR.
THERE'S NO REAL RISKS TO IT.
IT COSTS ABOUT $500 TO USE.
IT'S FDA-CLEARED FOR USE.
THERE'S NEVER BEEN A WELL
CONTROLLED, PLACEBO CONTROLLED
TRIAL OF IT.
WE'VE BEEN TRYING TO DO ONE
UNDER A NIDA GRANT, AND WE GOT
THE GOOD LUCK OF GETTING THE
GRANT JUST AS COVID HIT, WHICH
SORT OF MADE IT COMPLICATED TO
DO THE STUDY.
BUT IT'S AN INTERESTING DEVICE,
AND IT'S OUT THERE ON THE
MARKET.
ANOTHER SORT OF IN THE REALM OF
DEVICES I JUST WANT TO TOUCH ON
IS ELECTRONIC PILL BOXES.
WE'VE, AGAIN, GOTTEN INTERESTED
IN THESE DURING COVID.
SO THERE ARE THESE BOXES, SOME
OF THEM ARE BLUETOOTH-ENABLED,
SO YOU CAN LOAD THEM WITH THE
MEDICINE FOR 30 DAYS, AND WHEN
COVID HIT, WE WERE USING ONE OF
THESE WITH METHADONE PATIENTS.
THEY'RE LOCKED.
THE CELLS ARE LOCKED SO -- THESE
CELLS ARE LOCKED, THEY ONLY WILL
POP OPEN ON THE DAY THE PERSON
IS TO GET THE MEDICINE.
IF THERE'S A PROBLEM AND THEY'RE
BLUETOOTH-ENABLED, YOU CAN POP
OPEN AN EMERGENCY ONE IF YOU
NEED TO.
SO THAT SOMEBODY DOESN'T
NECESSARILY DOUBLE UP THEIR
METHADONE DOSE BUT STILL DOESN'T
HAVE TO COME IN TO THE CLINIC ON
A DAILY BASIS TO USE THEM.
SO THIS OPENS UP SOME
INTERESTING POSSIBILITIES FOR
USE.
AND WE'VE HAD A COUPLE OF
STUDIES SHOWING THEY'RE USEFUL,
THEY CAN BE USED IF PEOPLE DON'T
SMASH THEM AGAINST THE GROUND
AND THINGS LIKE THAT.
THEY ARE EXPENSIVE.
AND THE THIRD THING THAT WE'VE
GOTTEN KIND OF INTERESTED IN IS
PRESCRIPTION DIGITAL
THERAPEUTICS, SUCH AS RESET O.
I DON'T HAVE A SLIDE OF THIS,
BUT RESET O WAS MARKETED BY PARA
THERAPEUTICS WHICH UNFORTUNATELY
HAS GONE BANKRUPT, BUT THIS IS
AN INTERESTING PRODUCT.
IT'S A PRESCRIPTION DIGITAL
THERAPEUTIC.
SO YOU WOULD GO IN TO THE
MEDICAL ELECTRONIC MEDICAL
RECORD AND ORDER IT.
IT'S NOT A MEDICATION, IT'S A
THERAPEUTIC THAT'S ON A
SMARTPHONE.
THIS WAS TIED TO USE OF
CONTINGENCY MANAGEMENT AND IT
WAS A KIND OF CLEVER PROGRAM,
AND PARA DEVELOPED RESET,
RESET-O.
THEY ALSO DEVELOPED ONE FOR
INSOMNIA.
THESE WERE ALL PRESCRIPTION
DIGITAL THERAPEUTICS THAT REALLY
DIDN'T GET TAKEN UP SUFFICIENTLY
TO SUSTAIN THEM.
I THINK PROBABLY THEY SUFFERED
BECAUSE THEY WERE THE FIRST OUT
OF THE GATE WITH ONE OF THESE.
THERE'S ANOTHER ONE BEING
DEVELOPED PRETTY FAR ALONG BY
DYNAMACARE.
I THINK WE'LL PROBABLY SEE ONE
OF THOSE GET OUT THERE AND MAKE
A GO OF IT EVENTUALLY, IS MY
SENSE OF IT.
I JUST THINK PDTs ARE STILL
KIND OF A FOREIGN IDEA TO THE
PROVIDER COMMUNITY.
WE GET PRESCRIBING A MEDICINE,
WE DON'T THINK OF PRESCRIBING A
DIGITAL THERAPEUTIC IN THE SAME
WAY.
AND THEN NOVEL MEDICATIONS.
I'M GOING TO TALK ABOUT SE
SUVAREXIN.
THERE'S OTHERS AS WELL.
WE'VE GOTTEN INTERESTED IN ARE
THERE THINGS THAT CAN BE GIVEN
WITH A MEDICINE LIKE
BUPRENORPHINE OR METHADONE MAYBE
TO ADDRESS ANXIETY OR SLEEP OR
SOME OTHER PROBLEM TO EN ENHANCR
IMPROVE THE MAIN MEDICATION
BEING USED.
THIS IS A STUDY DONE BY ANDREW
HUNE IN OUR GROUP AND REALLY HAS
DEVELOPED A NICE LINE OF
RESEARCH LOOKING AT ANTAGONISTS.
HE DID THIS DOUBLE BLIND PLACEBO
CONTROLLED TRIAL.
IT WAS A RESIDENTIAL STUDY IN
WHICH PEOPLE HAD A BUPRENORPHINE
TAPER FOR OPIATE-DEPENDENT
PERSONS.
THEY GOT SUVOREXANT, 20 OR
40 MILLIGRAMS VERSUS PLACEBO.
THIS WAS THE FIRST STUDY THAT
CAME OUT OF THIS.
HE WAS LOOKING TO SEE IF YOU
COULD IMPROVE PEOPLE'S SLEEP
WHILE THEY WERE GETTING OPIOID
TAPERS.
THE SLEEP TIME WAS BETTER DURING
SUVO, THE GREY LINES, DURING THE
TAPER.
, WHEN IT WAS COMBINED WITH
BUPRENORPHINE AND THAT PERSISTED
SLIGHTLY BETTER DURING THE POST
TAPER TIME, WHICH WAS NICE TO
SEE.
SO THEN IF YOU LOOK AT
SELF-REPORTED WITHDRAWAL,
INTERESTINGLY SELF-REPORTED
WITHDRAWAL WAS ALSO BETTER WITH
LOWER RATINGS.
THIS WAS SORT OF UNEXPECTED,
REALLY DIDN'T EXPECT TO SEE
THAT.
AND THEN THIS WAS HOW MUCH DO
YOU WANT TO AVOID OPIOIDS RIGHT
NOW, A VISUAL ANALOG SCALE.
AND WHAT YOU SEE IS, THIS IS THE
THREE CONDITIONS, PLACEBO, 20
AND 40 MILLIGRAMS OF SUVO, AND
THIS IS THE TAPER AND THE
POST-TAPER PERIOD, AND THERE'S A
PRETTY ROBUST DIFFERENCE BETWEEN
THE PLACEBO GROUP AND THE SUVO
GROUP WHEN TREATED WITH
SUVOREXANT.
THAT'S REALLY GOTTEN A LOT OF
ATTENTION ACTUALLY.
SO PEOPLE WHO'VE GOT AREXIN
ANTAGONISTS ARE INTERESTED IN
THIS.
ANDREW IS DOING SOME FOLLOW-UP
STUDIES AS WELL.
THIS WAS A RELATIVELY SMALL
STUDY BUT MOVING FORWARD WITH
IT.
FINALLY I WANT TO TAKE A COUPLE
MINUTES TO TALK ABOUT, I THINK
AS WE THINK ABOUT THIS, I'VE
ALSO BEEN THINKING MORE AND MORE
ABOUT THINGS LIKE HOUSING FIRST
MODELS FOR THE HOMELESS.
I'VE BEEN SORT OF -- MY SON,
WHO'S IN HIS EARLY 30s,
ACTUALLY WORKS WITH THE HOMELESS
IN L.A., AND HE'S REALLY GOT ME
THINKING, WE'VE HAD A LOT OF
GOOD DISCUSSIONS ABOUT THE
HOUSING FIRST MODEL FOR
HOMELESS.
I JUST FINISHED A BOOK, I THINK
THE LAST NAME IS DUGAN,
HOMELESSNESS IS A HOUSING
PROBLEM, WHICH IS A REALLY
INTERESTING BOOK.
I HEARD HIM GIVE A TALK ON IT,
AND IT'S AN IMPRESSIVE SET OF
ANALYSES LOOKING AT TRYING TO
UNDERSTAND HOMELESSNESS, AND IS
HOMELESSNESS BECAUSE OF DRUG USE
OR MENTAL HEALTH OR WHATNOT, AND
HE MAKES A PRETTY COGENT
ARGUMENT THAT IT'S BECAUSE WE'RE
JUST NOT PRODUCING THE HOUSING.
AND THE HOUSING FIRST MODEL FOR
HOMELESSNESS IS A WAY TO MAYBE
START TO THINK ABOUT THAT.
THE BETTER INTEGRATION OF
SERVICES, AND ESPECIALLY BRIDGE
SERVICES, AND RAPID INTAKES TO
TREATMENT, SUCH AS STARTING
BUPRENORPHINE IN THE EMERGENCY
DEPARTMENT, WHICH I MENTIONED
BEFORE.
I THINK THESE ARE ALL THINGS TO
BE THINKING ABOUT.
THERE'S ALSO -- I DON'T WANT TO
OVERLOOK WHAT SO CALLED HARM
REDUCTION APPROACHES, WHICH I
WOULD NOTE, METHADONE AND
BUPRENORPHINE ARE HARM REDUCTION
APPROACH, BUT OTHER ONES, NEEDLE
EXCHANGE SERVICES, FENTANYL TEST
STRIPS, SAFE INJECTION
FACILITIES, AND HE HEROIN
TREATMENT.
I'VE GOT THOUGHTS ABOUT EACH OF
THESE, AND WHERE THEY FIT IN THE
CONTINUUM OF CARE AND HOW BEST
TO APPROACH THEM.
AND THEIR COST-BENEFIT ANALYSIS
OF THEM.
I THINK SOMETIMES WE MAY BE
LOOKING FOR FAST SOLUTIONS, SUCH
AS HEROIN TREATMENT, RATHER THAN
THINKING ABOUT WHETHER IT REALLY
PROVIDING TREATMENT TO HELP
PEOPLE WHO MAY BE
DISENFRANCHISED AND IN NEED OF
OTHER KINDS OF SERVICES, BUT
GLAD TO TALK ABOUT THAT FURTHER.
AND THEN JUST A MOMENT ABOUT
CREATING INTEGRATED SYSTEMS OF
CARE, THAT WE NEED TO BE
THINKING ABOUT INTEGRATING
PROGRAMS ACROSS LEVELS OF
SERVICE, MAKING SURE PEOPLE
ENTER AT THE APPROPRIATE LEVEL
OF SERVICE, AND IMPROVE
TRANSITION ACROSS LEVEL OF
SERVICES.
AND I'LL JUST SAY THAT WE NEED
TO THINK ABOUT MOVING BETWEEN
INPATIENT RESIDENTIAL
OUTPATIENT, THE EMERGENCY
DEPARTMENT APPROACHES, EACH OF
THEE ANDTHESE, AND HOW DO WE BER
INTEGRATE WHAT ARE SOMETIMES
DISPARATE LEVELS OR -- NOT
DISPARATE BUT NOT FULLY ENGAGED
LEVELS OF SERVICE.
AND WE NEED TO THINK ABOUT
LONGER TERM TREATMENT.
AS I'VE ALLUDED TO BEFORE THE
IMPORTANCE OF HOUSING.
TREATMENT OF THE WHOLE PERSON
AND THE SOCIAL ASPECTS,
PARTNERSHIPS WITH THE COMMUNITY
AND TURNING DOWN THE INFLOW, AS
I MENTIONED BEFORE.
SOME OF THIS, I WANT TO
ACKNOWLEDGE, I THINK IT'S
INTERESTING, NORA NORA VOLKOW,E
HEAD OF NIDA, HAS STARTED
SHOWING A SLIDE I'VE SEEN IN
SEVERAL OF HER TALKS OF WHAT
APPEARS TO BE A HOMELESS PERSON
UNDER A BRIDGE AND TALKING ABOUT
THE SOCIAL ASPECTS OF DRUG USE
AND NEEDING TO ACKNOWLEDGE THOSE
AS WE THINK ABOUT THIS.
DURING MY LAST YEAR OF EDITING
DRUG AND ALCOHOL DEPENDENCE, I
PUBLISHED A COMMENTARY ABOUT
NEEDING TO ADDRESS MEANING AND
PURPOSE IN THE OPIATE EPIDEMIC.
IT'S INTERESTING, IN ALL MY
PAPERS, IT'S THE ONE THAT I GOT
THE MOST, I THINK, EMAILS FROM
PROVIDERS AND THE COMMUNITY
SAYING, ABSOLUTELY, THIS IS WHAT
WE NEED TO BE THINKING ABOUT,
NOT JUST HOW DO WE STOP PEOPLE
FROM OVERDOSING.
WE NEED TO THINK ABOUT THAT, BUT
WE ALSO NEED TO THINK ABOUT HOW
DO WE ENSURE THAT WE'RE
ADDRESSING MEANING AND PURPOSE
IN PEOPLE'S LIVES.
SO LET ME SUMMARIZE SOME FINAL
THOUGHTS, SEE IF THERE'S ANY
QUESTIONS.
WE CONTINUE TO STRUGGLE WITH THE
OPIOID PROBLEM.
WE'VE BEEN DOING IT FOR YEARS
NOW.
I WOULD SAY WE DON'T HAVE AN
OPIOID PROBLEM, WE HAVE A
SUBSTANCE USE PROBLEM, AND IF WE
KEEP FOCUSING ON OPIOIDS, WE'LL
SIMPLY HAVE A METHAMPHETAMINE
PROBLEM OR A XYLAZINE PROBLEM OR
A BENZO PROBLEM OR AN ALCOHOL
PROBLEM IN A FEW YEARS, IF WE
DON'T ALREADY.
ADDRESSING THE PROBLEM FROM
HEALTH SYSTEM PERSPECTIVES
REQUIRES ENDURING COMMITMENT,
AND WE HAVE NOT BEEN GOOD ABOUT
THIS.
I THINK WE TEND TO -- I THINK WE
TEND TO SAY, OKAY, WE'VE GOT THE
CURVE GOING DOWN, WE CAN SHIFT
OUR FOCUS TO SOMETHING ELSE.
ALZHEIMER'S DISEASE, LYME
DISEASE.
THOSE ARE IMPORTANT THINGS,
ABSOLUTELY, BUT AS SOON AS WE
FEEL LIKE WE'VE GOT SOMETHING
UNDER CONTROL, WE TEND TO MOVE
ON TO THE NEXT THING.
WE HAVE APPROACHES THAT WORK
THAT ARE EVIDENCE-BASED.
WE JUST DON'T DO THEM.
, IS THE PROBLEM.
THERE ARE GREAT OPPORTUNITIES
FOR ALL TYPES OF RESEARCH IN THE
AREA OF ADDICTIVE DISORDERS.
I THINK -- YOU KNOW, MY CAREER
HAS BEEN IN THIS, IT'S BEEN
REALLY GRATIFYING AND
INTERESTING, INTELLECTUALLY
STIMULATING.
I TELL MEDICAL STUDENTS, IF
YOU'RE INTERESTED IN
UNDERSTANDING HOW RAISING TAXES
ON TOBACCO CAN DECREASE SMOKING,
THE SUBSTANCE ABUSE FIELD IS
OPEN TO YOU.
IF YOU'RE INTERESTED IN LOOKING
AT HOW DOPAMINE IN THE NUCLEUS
ACCUMBENS AFFECTS DRUG USE,
WE'RE THERE, WE'VE GOT IT ALL
FROM SOUP TO NUTS.
I CAN'T SEE WHY ANYTHING GOES
INTO ANYTHING ELSE, FOR THOSE IN
PEDIATRIC ONCOLOGY AND THINGS
LIKE THAT.
I THINK IT'S FASCINATING, EXCUSE
ME, AND REALLY INTERESTING.
AND THIS CAN BE EXTREMELY
GRATIFYING AS AN AREA OF
MEDICINE, IN WHICH TO WORK
CLINICALLY.
PATIENTS GET BETTER, AND THEN
OFTEN SOME OF THE MOST
APPRECIATIVE PEOPLE -- I CAN'T
TELL YOU HOW MANY PEOPLE I'VE
MET WHO SAY I DON'T CARE ABOUT
WHAT KIND OF TENNIS SHOES I
WEAR, I DON'T CARE WHAT KIND OF
CAR I DRIVE.
I'M WORKING MY PROGRAM, I'M
STAYING SOBER, I'M NOT USING,
AND I'M TRYING TO HELP OTHER
PEOPLE AS WELL.
AND THAT'S REALLY FUN AND
EXCITING TO SEE.
SO THANK YOU, AND WE'VE GOT A
FEW MINUTES FOR SOME QUESTIONS.
[APPLAUSE]
>> FIRST OF ALL, I THINK I'M
SPEAKING FOR EVERYBODY, THAT WE
REALLY ENJOYED YOUR WONDERFUL
PRESENTATION HERE, GIVING US
DEEP INSIGHTS, A LOT TO THINK
ABOUT.
SHOWING US IT'S NOT JUST A
BIOLOGICAL MEDICAL AND HEALTH
ISSUE, BUT OBVIOUSLY A SOCIAL
ISSUE AS WELL.
SO I GUESS PEOPLE HAVE
QUESTIONS.
I DO WANT TO KIND OF START WITH
MORE OF A COMMENT THAN ANYTHING.
IT ALWAY ALWAYS IRRITATED ME, WS
THE ROLE YOU -- YOU TALKED ABOUT
IT IN THE BEGINNING, THE ROLE OF
THE STATE LICENSURES AND JOINT
COMMISSION HAD IN ACTUALLY
ENCOURAGING OR ADVOCATING FOR
THE USE OF OPIOIDS TO TREAT
PAIN.
AND AT THAT TIME, WHEN THIS ALL
CAME OUT, LET'S SAY THAT IT
REALLY RUBBED ME THE WRONG WAY,
AND I WAS GETTING THOSE EMAILS
SAYING I'M NOT BEING AGGRESSIVE
ENOUGH IN TREATMENT OF PAIN.
NOW THAT WE'VE KIND OF
RECOGNIZED THAT, WHAT IS THE
ROLE OF THESE SAME ORGANIZATIONS
TO KIND OF TURN THAT AROUND?
>> YEAH, NO, SHOULD I REPEAT
QUESTIONS OR ARE THEY BEING --
>> THEY'RE BEING PICKED UP.
>> GREAT.
GREAT QUESTION.
YEAH, YOU KNOW, IT'S VERY
INTERESTING, BECAUSE I DID A LOT
OF -- NOT A LOT.
I DID SOME DIGGING LIKE ON THE
FEDERATION STATE MEDICAL BOARDS,
WEBSITES, THE JOINT COMMISSION
AND THINGS LIKE THAT AT ONE
POINT A FEW YEARS BACK, AND THEY
ALL HAVE LIKE BACKED OFF
TREMENDOUSLY IN SAYING OH, WE
NEVER REALLY SAID PEOPLE SHOULD
BE, YOU KNOW, DOING THIS.
AND I THINK THEY'RE PROBABLY
SCARED SOMEWHAT ABOUT THE
LIABILITY TO SOME OF THIS.
SO I THINK THAT WHERE THEY COME
DOWN NOW IS, YOU KNOW, IN
DOCUMENTATION, ELECTRONIC
MEDICAL RECORDS, THINGS LIKE
THAT, THEY'RE PUSHING TRYING TO
GET DECREASED PRESCRIBING OF
ANALGESICS.
BUT ACCEPTING ANY
RESPONSIBILITY, I HAVEN'T SEEN
THAT.
THE AMERICAN PAIN SOCIETY, I
THINK -- I'M LIKE 95% CERTAIN, I
THINK THEY WENT BANKRUPT.
I THINK THEY WERE SUED BY THE
STATES AND I THINK THEY WENT
BELLY-UP.
YOU KNOW, AS PART OF THE WHOLE
FIASCO.
>> THANK YOU.
>> HI.
LAUREN ATLAS, I'M A PAIN NURSE
SCIENTIST, SO I CAN CONFIRM APS
DID SHUT DOWN.
>> YEP.
>> THE U.S. ASSOCIATION FOR THE
STUDY OF PAIN HAS BEEN FORMED,
FOCUSING JUST ON RESEARCH ABOUT
PAIN, KIND OF, AND NO
PHARMACEUTICAL SUPPORT AND
STUFF.
I GUESS THE QUESTION THAT WAS
JUST ASKED SORT OF SETS ME UP
WELL.
AT THE END, YOU CONCLUDED WITH,
YOU KNOW, THIS IS AN OPIOID
PROBLEM, THIS IS A SUBSTANCE USE
PROBLEM, BUT I WAS CURIOUS ABOUT
WHAT YOU THOUGHT PAIN
RESEARCHERS CAN DO, GIVEN THAT
WE DID PLAY A ROLE AT THE
BEGINNING SO, YOU KNOW, YOU
MIGHT WANT TO ELABORATE?
>> SO IT WAS YOU?
[LAUGHTER]
>> I WASN'T AROUND THEN, BUT
YEAH, I AM CURIOUS TO HEAR WHAT
YOU THINK THE FIELD OF PAIN
RESEARCH COULD BE DOING NOW,
BECAUSE I THINK -- YEAH, I
GUESS -- I GUESS PART OF YOUR
DATA SORT OF SHOWED ME ACTUALLY
THAT OXYCONTIN IS SUCH A SMALL
PROPORTION RELATIVE TO THE
OVERALL OVERDOSES HAPPENING AS A
RESULT OF FENTANYL AND STUFF,
BUT DO YOU STILL SEE A PLACE
THAT PAIN SCIENCE SHOULD BE
REALLY THINKING HARD ABOUT THIS
AND HOW WE COULD AMELIORATE THE
ISSUE?
>> ABSOLUTELY, NO, I DO.
AND YOU KNOW, EVERYBODY'S SAID
THIS OR WRITTEN THIS, THE HOLY
GRAIL, OF COURSE, IS AN
EFFECTIVE ANALGESIC THAT'S
EQUIVALENT TO MORPHINE BUT NOT
WITH THE ABUSE PROFILE.
YOU KNOW, THE COLLEGE ON
PROBLEMS WITH DRUG DEPENDENCE,
WHICH USED TO BE THE COMMITTEE
ON DRUG DEPENDENCE, IT'S BEEN
AROUND SINCE THE 1920s AS A
COMMITTEE.
AND THEY WERE WORKING ON THAT
BACK FROM THEIR INCEPTION
SAYING, OH, WE'VE GOT TO FIND --
THEY KEPT THINKING THEY WOULD
FIND IT, MALBUFENE AND THINGS
LIKE THAT, WHERE THEY THOUGHT
THEY COULD FIND SOMETHING.
I THINK THERE STILL IS A ROLE,
ABSOLUTELY, AND ESPECIALLY FOR
ACUTE PAIN CONTROL.
AND WE NEED IT.
I MEAN, I JUST HAD -- NOT TO
PERSONALIZE THIS, BUT I JUST HAD
INGUINAL HERNIA SURGERY A COUPLE
MONTHS AGO.
IT WAS VERY INTERESTING GOING
INTO IT, BECAUSE I SAID, I DON'T
WANT ANY OPIOIDS.
THEY GAVE ME LIKE FIVE
HYDROMORPHONES, I THINK, OR
SOMETHING, TO TAKE.
AND IT WAS VERY FUNNY, BECAUSE
THE NURSE DIDN'T KNOW I WORKED
IN THE SUBSTANCE USE AREA AND
SHE GAVE ME THIS BIG LECTURE
ABOUT THE ABUSE POTENTIAL OF THE
OPIOIDS AND TAKE THEM TO THE
POLICE STATION TO GET RID OF
THEM IF I DON'T USE THEM AND ALL
THIS STUFF.
BUT I WAS STRUCK BY THE FACT
THAT I DIDN'T USE ANY.
I DIDN'T USE ANY.
YOU KNOW, I WANTED TO GET RID OF
THEM.
I SAID NO, WE'VE GOT TO PUT THEM
IN THE BOXY KEEP ALL THE
MEDICINES IN, IN CASE SOCIETY
BREAKS DOWN AND WE NEED THEM.
BUT I THINK -- YEAH, SO I THINK
STUDYING OTHER ALTERNATIVE
ANALGESICS.
I THINK THE OTHER THING, THOUGH,
IS, AND I COULD -- I WANT TO BE
CAREFUL ABOUT TIME, BUT YOU
KNOW, WE USED TO RUN INTEGRATED
PAIN TREATMENT PROGRAMS IN THIS
COUNTRY.
THEY CAME OUT OF THE UNIVERSITY
OF WASHINGTON-SEATTLE AS THE
MODEL.
THOSE WERE GREAT PROGRAMS, AND
THEY REALLY WERE EFFECTIVE.
WHEN I WAS A RESIDENT, THE ONE
IN HOPKINS RAN ON PSYCHOLOGY,
BUT IT RAN ON NEUROSURGERY,
ORTHOPEDICS.
WE'VE LOST THOSE AND THOSE WERE
GREAT PROGRAMS.
YOU THINK STUDYING THAT ON THE
CLINICAL SIDE AS WELL.
>> I THINK YOU HAVE TIME FOR ONE
MORE QUESTION, BUT WE CAN
TAKE -- DR. STRAIN WILL TAKE
QUESTIONS AFTERWARDS, AFTER THIS
IS OVER TOO.
>> I'LL STICK AROUND.
>> HELLO.
MY NAME IS RUTH, ACTUALLY FROM
ONE FELLOW AMHURST TO ANOTHER I
SAY HELLO.
SO MY QUESTION BOUNCES OFF OF
LAUREN'S.
BUT MORE FROM THE MEDICAL
PERSPECTIVE OR HEALTHCARE
PERSPECTIVE.
SO I UNDERSTAND THAT THE GOAL
OBVIOUSLY IN A PERFECT WORLD
WOULD BE TO CUT OPIATE OR
SUBSTANCESUBSTANCE ABUSE TO ZERT
WHAT WOULD BE THE GOAL FOR
DOCTORS IN REALTIME FOR
SUBSTANCE USE?
>> WELL, I WAS TALKING TO RITA
STEVENS ABOUT THIS WALKING OVER,
BECAUSE YOU KNOW, IF YOU LOOK IN
THE OLD TESTAMENT OF THE BIBLE,
YOU CAN FIND PASSAGES ABOUT
ALCOHOL AND HOW BAD ALCOHOL IS,
AND IT'S REALLY VIVID, ABOUT HOW
LIKE AT THE TOP OF THE MAST OF A
SAILING SHIP BUFFETED BY THE
WINDS, AND THE NEXT DAY I WANT
MORE ALCOHOL.
SO WE'VE HAD SUBSTANCE ABUSE FOR
THOUSANDS OF YEARS.
I DON'T THINK WE'RE GOING TONESS
NECESSARILY GET RID OF IT.
BUT I THINK WE CAN MAKE A KRA
DRAMATIC DECREASE IN USE.
I THINK, YOU KNOW, WE CAN DO A
BETTER JOB IN EXPLAINING TO
PEOPLE EARLY ON ABOUT THOSE
RISKS, THE RISKS OF EVEN
MODERATE ALCOHOL USE, THE RISKS
OF THE PRESCRIPTION OPIOID
YOU'RE GIVEN.
I MEAN, WE HAVEN'T EVEN TOUCHED
ON CANNABIS.
YOU KNOW, WE'RE IN THIS GRAND
SOCIAL EXPERIMENT OF MAKING
CANNABIS AVAILABLE, AND WE
REALLY DON'T KNOW WHAT THE
CONSEQUENCES OF THAT ARE.
I THINK WE NEED TO DO A BETTER
JOB AS HEALTHCARE PROFESSIONALS
ABOUT INOCULATING PEOPLE ABOUT
WHAT THOSE RISKS ARE FOR DRUGS.
>> SORRY, I MEANT TO ALSO
CLARIFY, SPECIFICALLY RELATING
TO THOSE WITH CHRONIC PAIN.
>> OH, OH!
>> YEAH.
>> I THINK -- SO I THINK WE LOOK
AT OTHER TREATMENT MODALITIES
FOR CHRONIC PAIN, LIKE THOSE OLD
UNIVERSITY OF WASHINGTON, YOU
KNOW, PROGRAMS WHERE YOU GIVE
PEOPLE A VARIETY OF TREATMENTS
BEYOND SIMPLY SAYING, WELL,
HERE'S AN OXYCONTIN
PRESCRIPTION.
THANKS.
>> THANK YOU.
>> DR. STRAIN, THANK YOU VERY
MUCH.
I WANT TO THANK THE AUDIENCE FOR
THEIR QUESTIONS, AND THIS GIVES
US A LOT TO THINK ABOUT.
SO ENJOY YOUR AFTERNOON AND FOR
SOME REASON I HAVE A VERY ODD
CRAVING FOR APPLE PIE AT THIS
MOMENT.
ANYWAY, THANK YOU. 1809 01:02:19,969 >> THANK YOU.