Articles, Blog

Opioid crisis | Pain Relievers are leading to a New Drug Injection Epidemic

December 28, 2019

Welcome students and prospective candidates and alumni I’d like to take a few moments to thank you for joining us today for this amazing learning experience and As your maphsa executive board member and also your mph online student ambassador it is my responsibility To help seek out events that represent our students interests USC Master of Public Health students are extremely interested in our nation’s opioid crisis and They desire to learn more about how to address this issue as public health professionals With the CDC’s March announcement of a national 30 percent increase in overdoses from 2002 to 2006 teen to 2017 this discussion could not be more timely It is an honor to introduce today’s hot topic speaker and educator Ricky Bluthenthal, PhD He is not only faculty in our preventive medicine department and Master of Public health program But a research expert and authority on our nation’s opioid epidemic we are very fortunate to have him as one of our professors and Please join me in welcoming this amazing guest we are sure to learn a lot from him welcome dr. Blumenthal Thank you for those kind words Why don’t we get started? So for 25 years I’ve been conducting research on Health issues related to injection drug use I began With a response to the HIV epidemic And stuck with it long enough to now be dealing with this addition this new challenge to public health For people who use drugs, which is the opioid crisis an attendant overdose death and other? Health out health ailments that are I’ll discuss more in more detail later on so let me just get started So I’ll talk about how we ended up with this prescription opiate epidemic, or crisis I’ll talk about the health consequences of it and then I’ll provide some Recommendations about how we might respond? Respond to this nationwide crisis and may just make a point that you know I started with HIV In the United States HIV really was relegated mostly to cities in large measure And I’ve obviously had an outsized impact on minimum sex with men and to a lesser extent people inject drugs, although certainly in the Northeast there was a substantial HIV epidemic among that population – part of what distinguishes the British opiate epidemic from prior crises Is that it really is impacting all of us in all kinds of different settings so rural urban suburban White black Latino Asian you know sodor no one is immune to the consequences of this and I’ll sort of I’ll begin to explain why that’s the case? So the opiate epidemic Basically has three. It’s a three-legged stool The first the first leg of the stool was a change in in medical practice related to pain in the early 90s it was widely Conceded that physicians were under treating Pain and so there was an effort Led to sort of change that so physicians became more interested in treating pain Now that created some in there sort of this idea of the as pain as a fifth vital sign And that created some unintended consequences So one of which is that pain is very subjective So we all experience it differently we could have the precisely same Injury and have widely different assessments of how much it hurts And we know there’s not a great understanding of that Another problem with pain is that? Typically when someone’s prescribed the pain medication if there’s a problem the recommendation is sort of give them more of that pain medication And in the face of these sort of new opiate medications that becomes a real problem And then finally there was a real move away from just using opiates to treat acute pain And so you might think about that if any of you had your wisdom teeth taken out you were probably given in an opiate kind of pain medication You know and they’re great for treating acute short-term pain That’s why they’re widely used in the military when people are shot or injured The but the move of them into chronic pain created a whole separate set of problems So that’s one stool pain is a fifth sign the other was new technology so pharmaceutical companies develop these long-acting opiate medication so the typical opiate medication will last four to six hours these new formulations Were advertised as lasting eight to twelve hours Which has some modest advantage in sort of taking fewer pills But I think it’s now well documented both in popular literature in the scientific literature That they’re not necessarily that long-acting and some of that just relates back to the issue of pain being a subjective Subjective kind of phenomenon Regardless there really didn’t go through the trouble of establishing that these long-acting approaches were superior to the short acting formulations The abuse potential for these medications was not established before they became widely Distributed in the fact that manufacturers claimed that they had low Abuse potential which we now obviously know it’s not true, and then of course the other pieces that when you use these medications Outside the context of either chronic or acute pain the euphoric effects are substantial so they they make you very high To put it a different way, and so they’re highly desirable as a recreational drug Then the third leg is pharmaceutical marketing now these are large multi-billion you know large companies global in nature billions and billions of dollars of annual revenue and profit so their capacity to Make sure that these medications were widely available to anyone who might possibly need them are really impressive In the case of the one of the manufacturers there was a successful effort to target physicians And they began by focusing on physicians with high rates of OB They were spending Enormous amounts of money marketing these medications to physicians and when in one case a company spent Over two hundred million dollars on that and another year they reached 90 thousand physicians in the United States Because the dis because the the distribution system is through medical care It’s sort of available in every zip code or many zip codes and then lastly this again the shift away from acute pain to chronic Which is driven. You know if you’re a pharmaceutical manufacturer their real advantage There’s a lot more people with chronic pain than acute pain and so that shift to current using these medications for chronic pain sort of created the circumstance We’re in so this chart Just shows you the massive increase in prescription opiate availability in the United States And so the way, I think about this is essentially What we’ve created a circumstance Of is that? for anyone who might misuse opiate prescription medications they probably had a chance to do so That could happen through diversion so someone in their family gets those medications Excuse me, and and don’t you doesn’t use all of them So there’s some left in the cabinet the medicine cabinet, and they begin using that way That could happen from people who have an acute or chronic pain injury who begin to misuse as a way of managing both the pain or of achieving highs, and it’s worth pointing out that the One of the challenges with these medications is if if you continue to have pain You know they will prescribe higher doses Which will facilitate this sort of process of becoming physically dependent which is sort of a unique quality of opiate medication so if you stop using them you feel very sick or unwell And then the other piece of it is that the sort of some patients Became miss users from sort of this escalation of to treating their pain The other thing is is that if you take these medications for a long time You can develop a condition called hyperalgesia Which makes you really sensitive to pain and so you’ll ease you know so you sort of a caught up in the cycle of You know you’re more You’re hypersensitive pain So you start off you had a pain problem the medications perhaps dealt with it Or didn’t deal with it you took more of it You’re now physically dependent And then you’re even more sensitive to pain so you wanna your desire to take more increases even more? So you know those are the conditions that sort of? Have emerged for us and You know as a consequence There’s obviously there’s been a response so one of those responses is the development of these abuse to turn pill formulations And what those the goals of those those medications or to not allow you to break the pill down The reason why people would break the pill down is that if you take a long-acting pill and say crush it to snort it or Liquefy it to inject it the euphoric effects are substantially greater So you you you get a uniform of a better term a better high? so we’ve had the introduction of these new pill formulations to To work against that although you know they’re not They’re available now They’re in use But they’re still the old kinds are so available There’s now prescription drug monitoring programs in most states, and what that basically is is a repository of all prescriptions given to people and what it allows physicians to do is if they have a patient in front of them for Whom an opiate medication might be indicated they can look into this prescription drug monitoring Website and determine whether the person already has outstanding medications for that so it’s a way of dealing with the issue of doctor shopping and sort of drug seeking in various medical facilities the other thing is the FDA and Cities and states have actually suits excessively to prescription opiate makers in a variety of settings But you know owing to some of the changing political dynamic United States those settlements are tended to be on the smaller side and certainly You know in the case the last case. I looked at I think a manufacturer agreed to pay West Virginia 25 million dollars But you know they’re making billions of dollars on the sell of these drugs So a twenty five million dollar fine here, are there is not going to stop them or deter them so Beginning since 2011 we’ve had this sort of substantial design Decline in opiate prescribing the president the other day indicated that he’d like to see that drop another 30% Which sounds well and good But there are some problems with sort of rapidly removing These medications from circulation now that everyone has sort of been Been exposed to them so this chart shows you Sort of this is from the National Household Survey national survey on drug use and health shows you past year initiation past year misuse and past year Disorder for prescription opiates which are in the blue and heroin which is in the in the red and? You know the key point here is that we’re sort of in a pickle now, so we’ve exposed lots of people two million people initiated prescription opiate misuse in 2016 another Almost two hundred thousand initiated heroin use we have nearly 12 million people With past year prescription opiate misuse and nearly a million heroin Mis users and then high numbers of people with opiate opiate use disorder and heroin use so one of the things that’s going to happen as we pull back the Legal the available is a little legal medications is that people will begin to move into illegal substances So we’ve seen if you just look at the last bullet a five-fold increase the number of heroin users in the last decade And the reason for that is that heroin is pharmaceutically similar to prescription opiates It’s also less expensive In illegal market so in Los Angeles for instance you can buy a what’s effectively a dose of heroin for ten dollars whereas buying a prescription medication Opiate would cost between 30 and 90 dollars sort of depending on the amount of the milligrams of opiates in the in the particular pill Heroin is now widely available in urban settings and is increasingly available in suburban and rural settings to match the market demand That’s been sort of created by these by the pharmaceutical drugs so You know these are because we’ve been out a couple reports. We don’t have great data on this, and we don’t have really good surveillance That allows us to understand Transitions between drugs so even the National Household Survey is a cross-sectional study There are relatively few local cohorts of non Injecting drug users that we can sort of follow And see how many people translate trends are transitioning from opiates to heroin or from heroin to injection. Here’s some of the data That’s available at least on that first point of movement of people from prescription misuse to heroin use so the first study saw about four percent Movement in five years Carroll sins with Carlsen’s which is the most recent study from, Ohio? Found among prescription opiates opiate users about three percent of them became heroin users and then Sarat looking at a group of Club drug users many of them were men of all sexes men saw an annual take a seven percent So the so the thing to think about though is that that translates into a real number at the population level so if there are 12 million people With prescription opiate misuse you know seven five percent of them moving into heroin use is a substantial number of people hundreds of thousands of people and so That’s going to continue to be a challenge for us moving forward So injecting heroin similar to injecting prescription opiates creates a better high There’s some forms of heroin so the heroin that’s available west of the Mississippi tends to be black tar heroin so it’s more difficult to use without injecting and We also know from the National Hospital survey that of the people who use heroin half of them injected And that compares to 13% for meth users and cocaine users, so The sort of premise is is that we have all these things happening. We have an overdose epidemic I’ll show you data on hepatitis C and HIV outbreaks There are a variety of other ailments coming with that, but we also have which has not been talked about an emerging injection drug use epidemic That’s going to have substantial public health consequences So the way, we’ve looked at this is what using low all day They’re from San Francisco, Los Angeles, and this is based on sort of two studies. I’ve conducted In the last eight or nine years One to cross-sectional study that was the first one in 2011 13, and then I have a cohort study That’s ongoing now And what we’ve tried to do is sort of bring in some I guess what I would call sociological context into understanding drug use Drug use patterns so the first one is the sort of idea of drug use generations And if you sort of survey drug use patents the United States you would see You know an evolution of people moving from away from heroin in the 60s towards cocaine and then from cocaine to crack cocaine in the 80s From crack cocaine to meth in the 90s and 2000 and then from math to this prescription opiate stuff Which is sort of in the nineteen? That really beat really took off in the 2000 so in that sort of the current place. We’re at And that’s useful to think about because that the the one of the underlying I think principles of drug drug misuse Is that if you are susceptible for drug misuse you end up using the drugs that are available at the time? and And the implication of now having this opiate Be opiate be the main problematic illicit drug Has real consequences because opiate users tend to use four years not? In decades not months and years which kind of characterised You to the crack the cocaine the crack cocaine and even to a lesser extent the methamphetamine Cohorts or people you know will start the mess around with it for a while But typically they’ll age out of it or their life circumstances will change, and they’ll move out of it Or they’ll just get get burned out we know from the earlier generation of heroin users that came out of the Vietnam War era You know those folks continued to use for 20 30 40 50 years And that’s what we’re looking at now, so we’re going to have a problem That’s going to go on for a long time so using this idea about drug use Generations, that’s helpful and sort of contextualizing the implication the change from Math to prescription opiates the other thing we do is we use this drug set and setting model Which again sort of underscores the need to look at the pharmacokinetic? attributes of the drug and how that impacts use patterns And I sort of already described that to you, and then finally life course theory is helpful and looking at How people age or don’t age out of drug use and then how they remain vulnerable And you know one of the early warning signs of the prescription opiate crisis was the fact that you saw older people requesting substitute substitute medically assisted treatment or opiate substitute treatment In Different demographic groups, and that’s you know that’s unusual typically if we’re going to misuse drugs. We will misuse them through our 20s But most folks age out of it and so when you begin seeing 40 and 50 year olds requesting treatment For methadone or buprenorphine, then you know that you’ve got a you’ve got a different you’ve changed that the life course framework of drug use in the United States All right So I’ve sort of briefly described the studies one the first ones cross-sectional the second is a cohort study were in the midst of Still collecting our six months and 12-month dated for that So the characteristics of my sample mostly male um But a little less than 15 to 2 B to 15 20 % gay lesbian or bisexual mostly white but with decent representation of Latinos and african-americans the population I see is largely homeless and You know one of the next things I’ll be working on is this big jump in the prevalence of homelessness which went from 60% in the 2011 13 kampl to 80% over 80% of the 2016-17 and then in and then we’re also seeing a basically doubling of younger people between the – the two studies Alright, so part of what I that We’ve done with this work is just begin to map on that this population of people who inject drugs actually can give us a Some a window into understanding national drug use trends, and so this slide just sort of Is my attempt to sort of match those two things so what you see is a the proportion of the sample that? report using this drug for the first time by half decades and you see we have a Heroin peak in the late 60s. That’s been replaced by a cocaine peak In the late 70s and the crack copaque coke cocaine peak in the late 80s and then map jumps up And then you see math being surpassed by prescription opiates Going into this last period of 2005 to 2009 so we so I think this this sort of makes a case for saying Yeah, it’s reasonable to use this kind of sample Using their retrospective reports to sort of understand national draw houston’s so the first question is you know what are the implications of having? prescription opiates be the sort of main illicit drug that people are using them and this shows you one of those that change so one of the implications is the move of prescription opiates from being relatively infrequent initiator of opiate use Most folks start in the eighties and so what this shows you trying to explain. It’s a little bit complicated. Is that the first? Column the pre sixties generation so this shows that About 12% of them are 15 percent of them started their opiate use with prescription medications And then most those start with heroin which was this middle one and then at the same age? And then if you just look at the first bar in each column you see it grows substantially so by the 1980s Nearly 70% of people their first opiate is the prescription drug or they’re using them in the same year? Which is a? on the far right So that’s a big. That’s a big change and part of the implication of that is you know again heroin What is not widely available although increasingly it is? Presumed opiates are everywhere and so that’s what’s sort of driving. This is that you you get the sort of generational switch and drug use patterns And this is sort of another way of representing this now. This is looking at the first drug injected And what we saw here what we see here is the top line is heroin and the bottom line is cocaine or meth And so again reflecting the surge drug use patterns the first drug injected was increasingly a speedy drugs or cocaine or meth but then as These new chords come on you see begins to go down and instead We have heroin becoming the first drug we inject and if we drew another line out From the 90s we didn’t have a lot of people in the sample who were born in the 90s But the number continues to go up So we’re going to have more heroin Injection as a consequence as a sort of follow-on from the prescription opiate crisis, so then the next thing again trying to make the point about how Opiates leading to heroin leading to injection sort of changes the injection drug use epidemiology in the country we sort of developed two measures one of them is a One of the one is sort of time to injection and that’s a broader measure Focused on one how old were you when you first used an illicit drug, and then the you first injected any drug right so That’s just one measure of time. That’s one time two injection, and then we have a second one that asks the question When you you first use any drug how long was it before you injected it? And all of this the take home for this will be Largely that the the uptake of heroin means that we’re going to end up with a lot more injection drug users moving forward So just looking again remembering that we had this change of people using more heroin injection This is the overall time to time from first use to injection by birth cohort again and You see it was pretty low for the pre sixties generation that was mostly exposed to heroin and then went up with cocaine and crack Cocaine and now it’s going down again And you know we’ll be able to look at this in my new sample, which has many more people born in the 90s But I would expect that the bars for the folks born the age cohort born in 1990s would be even shorter And then this just sort of looks at that using Multivariate regression so linear regression model with time to injection as the Dependent variable and the key thing here is we just look at the bottom two rows We see there’s a negative number with the 1970s as a referent and what this indicates is that? folks born in the 80s were significantly had significantly shorter times to injection as Compared to folks born in the 70s which sort of reinforces that point All right, so then we use for up revival analysis techniques to look at time from first used to first injection And again this sort of shows this unhappy story with heroin users median survival time is a little more than a half a year so from the first used of heroin to your first injection less than Less than a less than a year It’s over a year for speed and then much much old much much longer for the cocaine and crack cocaine And then within ten years of first use ninety-three percent of the heroin users will have injected as Compared to 78 percent for meth and 70 percent for Coke for cocaine users and then thirty percent for crack cocaine users And then last this is just a representation of data again And the point of this is just to show that a lot of that action really is in the first year so the slopes on these lines are not significantly different But what is different is the entry point so that first year of use? And seems to inevitably lead to injection for most most heroin users All right so the opiate epidemic associated a more rapid transition to injection drug use and the people using heroin Which is the drug that sort of follows on naturally from prescription opiates are going to end up injecting? All right, so one of the problems with having more injectors Is that in a way injection baguettes additional injection and so let me explain what I mean by that? So we conducted that initial study twenty eleven to thirteen was a study on how people basically asked a question how do people become injection drug users and what we found was that it is an a It’s a it’s a process. It’s a social learning process, so folks would be the stories that people told us about their pathway to injection involved exposure to injectable drugs Being around people who injected drugs an opportunity to receive instruction an injection and then actually getting assistance Injecting you know most of us don’t like getting shots. We’re needle phobic. It’s difficult to hurt yourself intentionally which injection Requires and so basically 70 to 90 percent of people who ever inject need help injecting that first time And so this sort of social learning process sort of summarizes that process so we’ve asked questions of people Like have they do they encourage others to inject drugs do the injector foot of mountain injectors do the escribe injection to non injecting? Understanding that these are potentially precursors to injection drug use for non injectors and what this shows you is that these sort of precursor behaviors are Associated with initiating people so if you’ve ever described injecting to someone you’re more likely to have initiated someone in the past 12 months We also Looked at whether you’re being asked and that sort of Is a good measure of that so that the person who currently injects is sort of involved in that social learning process And what this basically just shows is that? When you do these precursor behaviors when you inject in front of non injectors when you describe injections and non injectors or when you do both You’re going to be much more likely to be asked to initiate someone for the first time And this is sort of as a chart a figure that sort of shows that again the bottom one has ever initiated someone You know if you’re not injecting in front of non injectors. If you’re not describing it if you’re not doing both you’re very very low probability of initiating someone either in a lot of 12 months or ever which is the middle line and Then you see the thing about being a switch is the top line Okay, so one of the things that’s disturbing We know that heroin use has increased based on the national surveys the data that we’ve collected in San Francisco and Los Angeles indicates that injection both from the changes in the demographics of our sample But also in the self reports from people who currently inject It looks like there’s more initiation going on so you can see these are comparing the 2011 13 samples of 2016-2017 sample recent initiation was 7% in the order sample, it’s 13% in the in the newer one and we changed the question so the question in the newer one is for the last six months so That number if we if it was annualized it would probably be higher describing injections gone down, but injecting in front of non injectors Has gone up and that probably has something to do with the increased homelessness? And then a willingness to initiate people the future is basically equivalent so just so you know I am trying to do something about that and my current study the sort of second one is a short hour long Active listening motivational interviewing intervention with current injection drug users to sensitize them to the risk of the sort of precursor behavior and then to provide them with behavioral skills and role-playing Opportunities to sort of figure out how to get out of those situations that they find them find themselves in them Alright, so one of the consequences of all of all this that they’re they’re relatively horrific in 2015 Scott County Which has about 40,000 people in it at an outbreak of HIV and hepatitis C among their among the people inject drugs there Those 102 183 infections in a year just to give you an idea, LA County Which has 13 14 million people in it has 56 injection drug use related HIV cases in that same period of time So 40,000 people will 183 HIV infections to 56 with 13 million people there documented outbreaks of hepatitis C in, Kentucky, Tennessee, Virginia West Virginia most of those cases now because we have a clean drug supply or going to be from injecting drugs so sharing syringes or sharing cookers cotton or other drug use injection paraphernalia HIV incidence has increased among young people in non urban counties We’ve seen dramatic increases in abscesses of skin and soft-tissue infections that are often associated with Injection drug use. We’ve had these increases nationally in in North Carolina and infective in hospitalization for infective endocarditis related to drug injection We’re seeing this age cohort difference now so acute HIV kiss season acute hepatitis C Rates have increased among young adults and so the difference between the acute hepatitis E. Case of chronic as I see cases acute cases new So those are folks who’ve been affected in the last six months dramatic increases after long-standing The Pines among hall populations again that tracks with increasing evidence of more drug injection in the United States This is data from California showing the age distribution of chronic hepatitis C cases So we went from having a nice little bell curve or one hump camel to now emerging to have a two hump camel as younger people begin to increasingly become infected with hepatitis C And then you can see this is some representation if it’s darker means more hepatitis C And this sort of underscores again the you know almost global impact, or you know it’s sort of hitting everywhere So we have increases in Los Angeles Serban the quintessential urban commune in California increases in the bay area, but also increases in these sort of urban or rural areas in Northern, California Where folks are moving You know or getting getting have been exposed to prescription opiates are Misusing them through injection or perhaps transitioning to heroin if that’s available in their local communities And then we’ve all talked to there’s no law to talk about the overdose stuff So there’s a so there’s sort of two qualities of this earlier. I made the point about as we pull back prescription opiates We do run the danger of people moving to the illegal alternatives and that happens so you see this reflected in the heroin overdose deaths Beginning in 2010 how they’ve gone up dramatically and then the thing that The begin to happen in 2013 is that the heroin supply became contaminated with synthetic Synthetic opiates the main one being fentanyl, this is a problem because fentanyl is 10 to 50 times more powerful than heroin So the risk of overdose increases dramatically And that sort of it’s a sort of contamination thing, so folks don’t This may change, but at the moment for instance in Los Angeles folks aren’t buying fentanyl. They’re buying heroin But it’s been contaminated with fentanyl, and this is sort of happening throughout the country so We have out we have these HIV hepatitis C outbreaks We have the overdose crisis the contaminated drug supply Increasing drug injection and a treatment system in the 25 years. I’ve been doing this stuff that has not Increased to match the problem And so we’re poorly prepared To to deal with this, but there we do have lots of options So let me just start with the first principle which is that? We need many approaches not just one and you know as you follow this debate in the newspaper Or as you talk to local decision makers or state decision makers of your Nationals This is makers keep in mind that there isn’t one solution to this so there You know we’re going to need to sort of open the full box and take a look at all kinds of different options so this was a Cascade approach that we developed We weren’t able to test it, but we did a couple colleagues of mine Pete Davidson. Who’s at UC San Diego? Source on a scholar who now works for the LA County and Carl Castro, who runs our military health center here at USC We put this together just looking at this And it just the idea is just to highlight the different kinds of choices if you’re trying to deal with diversion You might want law, but you know lock cabinets or lockable pill boxes if you have patient driven diversion You know you might want to use peer River or referral to injection drug use if people are to drug treatment rather? If people are selling them you might want to get someone a job, so they don’t have to sell drugs and said if their self medication get them adenosine n’t provide them with overdose prevention training or naloxone And then referral to drug treatment, so there are lots of things to do I’m just going to take you through a little bit of a laundry list of what some of those things might be So we can do demand interventions to prevent Injection initiation so part of that would be making drawer treatment more widely available But there are some sort of cognitive behavioral Interventions the one that Dante’s related back in the 90s that sort of tried to arm current non injectors with information about how to About why they wouldn’t want why they why they don’t want to become injection drug users? There’s this combined structural interventions that Daniel Warp is at UC San Diego in the University of Toronto is exploring which looked at combinations of drug consumption rooms increased medically assisted treatment housing first and decriminalization of illegal drugs We can do what I’m doing with the existing population of injectors and try and move them away from facilitating an injection uptake And I’ve already described that to you the middle the middle bullet. It’s the one we’re doing which has changed the cycle Now obviously no oxygen distribution has been very important the Peer drug users and drug injectors are among the most effective respondents to overdose They know how to know what it looks like if you arm them in the hawk zone. They’ve shown over and over again They’re more than happy to use it And it probably been very effective and you know we’re sort of Collecting more and more data about this about how effective this sort of approach has been to preventing overdose deaths And then we spread first responders now Obviously from paramedics and carrying naloxone for years, but now police are increasingly carrying them carrying it as well You can see this just shows the rapid uptake now and distribution of naloxone in the country so it’s important important Development so here. I just that we use the data again from our 2011 13 sample 2016-17 so the lighter is The later one and these are broken out by City and the key thing here is just to note that You know we’ve seen increases in overdose between the two samples probably in part because of the fentanyl contamination Many people inject drugs witness overdoses, so they’ve gone up dramatically in Los Angeles, but most importantly We’ve also increased on the locks own distribution And so it went from being used four percent of the time when someone observes an overdose to almost 70 percent of the time So this shows you the power of Drugging drug users to be health interventionist in the midst of this particular crisis The same thing has happened in San Francisco services we had a little bit higher baseline of naloxone distribution but you know now 90 percent of the witnessed overdoses someone in the community is reversing that with an auction which is a tremendous help a tremendous help health benefit The other hot topic is the safe injection rooms they accomplish a variety of things So there are about a hundred in the world. No one’s ever died in one of them. I’ve visited Probably four or five of them over the years the sort of clean well-lit places to use drugs They’re very effective at perennial dosed us. They’ve been documented to provide a Great Avenue into services including substance abuse treatment and housing they obviously because people are using a loan Reduce any risk of HIV or hepatitis C transmission because the setting is clean you should see declines in the defective card ID in the endo carditis and abscesses And then finally because people aren’t using out in the community that using these facilities That reduces the socializing aspect so in fact in Switzerland They have Had safe consumption sites for many years since the 90s And if I do heroin prescribing and have seen a dramatic decline in their population of drug injectors Because the current cohort of people who use don’t use in the community They use in this facility and so they’re not in a position to socialize others into the use Of course we need to expand treatment dramatically. There are a whole set of regulatory and legal Impediments to that that we need to overcome in fact. I went to having a conversation with a pharmaceutical Maker earlier of manufacturer earlier today and learned of a new way in which we sort of prevent ourselves from making These these evidence-based treatments as widely available as they need you know for me The gold standard really has to be that we need to make legal treatments or substitutions as Readily available as the illegal drugs are and less expensive than them so right now in Los Angeles It’s a lot easier for you to get heroin than it is for you to get drug treatment And we need to change that and this just sort of underscores that point we’ve had you know there’s been great progress in improving methadone Availability and buprenorphine, but if you refer back to my earlier slide remember there are almost 2 million people last year that had prescription opiate disorder and another 600 700,000 and heroin use disorder and there are only 400,000 methadone slots similar there are only 55,000 buprenorphine slots so that that capacity is insufficient to meet the demand that we have And then this is just a little list of different things you can do and how they deal with the sort of downstream consequences of the opiate The opioid epidemic including drug injection these HIV outbreaks overdoses fentanyl a lot of things that we can do and And we need to move on it quickly you know what I’d like to see and what I would have liked have seen yesterday when the president was addressing this topic is a response like we saw for the AIDS epidemic where You know billions of dollars were put into the fight to develop new medications to provide Preventive services to make sure people have asked access to care, and we’ve made tremendous improvements in that HIV is now chronic ailment Most people certainly in developed countries receive care many people in developed countries now receive care And that’s sort of what we need to look for in terms of the prescription opiate crisis. Let me just conclude by acknowledging funding from the National Institute of drug abuse Our project officers my best friend and collaborator Alex crawl and then the community participants research assistants Students at USC who have all contributed to this work. Thank you for your attention So we’ll do questions now Yes, thank you. Dr. Blumenthal for that sharing that information We will not now try the answer your questions to submit a question Please type it into the Q&A box in the lower right hand corner of your screen and hit Send Dr. Gluten all he shared a lot of very important information with us, and he’s happy to answer any questions that you have We do have one question right now dr. Blumenthal One of our attendees asked, can you briefly describe a little bit more about the? Pharmacogenomics and the opioid epidemic and where are we with that? Probably not I’m not sure what pharmacogenetics are Okay you give me a little bit more about that. All right. I’m so sorry the Pharmacogenomics and the OPA no I don’t know what that is So tell me what that is, and then we’ll try to answer it Sorry Okay, no problem. We will move on to them to our next question Our next question is of what’s considered abuse of opioid use if an individual’s tolerance is higher than average users Yeah, I mean I think you know basically. I mean there are a couple of definitions of addiction out there You know typically it means For one of a better term I mean the search one would be sort of you know repeated use with negative consequences So you’re using so much that you can’t do the normal things that you would typically do The so you can have situations where someone is dependent on an opiate But it not be addiction and so cases like that might include folks with who are terminal cancer patients And so they’re taking it for pill for pain relief For the cancer they’re dependent on it, but it wouldn’t be considered addictive behavior Because it’s used to sort of deal with the sort of in life Moment that they’re going through you Know the issue is really What are the other things happening around you that lead to negative consequences? whether it be driving high or missing work or Selling your toaster. Oh And so here’s one so how does genes so this is the pharma Gen X? Thank you? Reidel so how does that affect a person’s response to drugs? So thank you for clarifying that? You know I do not know the answer to that question Let me just tell you what I think generically about Genetic explanations for substance abuse which is that? I’m sure that there is some contribution and we know that you know there’s some genetic markers for instance for alcohol and we know There’s some genetic Predispositions that certain populations have that make alcohol use more problematic for them those probably do exist For opiate medications as well You know I you know, I’m a sociologist the part of the problem I’m focused on more is the the other dynamics Which is that regardless of what your genetic profile is if you’ve been exposed to these drugs? And you begin to misuse them we do have relatively consistent outcomes from that And the genetic contribution to that as far as I know is not is certainly not well understood So I just keep going to the list jennifer yang Can we treat opiate abuse as a chronic disease? Well, yeah, it is a chronic disease. That’s for sure I think one of the areas that people are going to really begin focusing on is that pain is a chronic ailment And we need to come up with other ways of treating pain that don’t involve prescribing folks drugs that are highly addictive So I just keep going guys or Absolutely dr. Blumenthal Okay, and then there’s a question from Douglas about what are your thoughts on how the opiate epidemic affects state or federal? public Public health policy for treatment conditions are concerned Okay, so this is I actually learned something about this today, so let me I will try and share this with you And there are a couple of thoughts related to it, and I’ll end with the thing that I learned today Okay, so the first thing that we one of the problems that we’ve had I talked about medically assisted treatment, so that’s methadone and then buprenorphine. Those are the two main medically assisted treatments They’re highly desirable because they really are effective so people who use these medications you know their their use of illicit drugs go down substantially They’re great benefits in terms of employment and housing and social you know their ability to sort of have lives that look like they don’t have Any drug use history so they’re there they’re really powerful that way unfortunately they’ve also been heavily regulated There have been changes most recently in the legal status are none Can prescribe so for instance there was just a new directive that came out a couple of months ago from the federal government? Then now allows nurse practitioners and physician assistants to also prescribe buprenorphine So that’s a that could be very helpful moving forward Now one problem is so we have this Medicare system and Medicaid expansion so many more and we also have parity so You know substance abuse, which is a mental health illness? Should be treated the same way as a broken arm in terms of availability of treatment But there’s a thing beat that sort of happens behind the system that gets in the way of that So let me tell this so this is a new thing. I learned so there’s these things called pharmacy benefit management organizations that basically create the form of the the the farmer the farmer call the pharmacy formulary, so that’s the drugs that a provider can use to treat you know XY and Z and because of market dynamics in that system some of the best kinds of and most innovative substitution medications actually aren’t available through people’s health insurance and The example I learned us today was this drug this buprenorphine Alternative called Buena Vere Reno Vale, which is you know it’s a soft box own? So it’s a buprenorphine medication that you use as a film So it’s just like a little little piece of paper that you ingest has lower side effects, but it isn’t widely available Because the manufacturer of them hasn’t been able to get through the pharmacy benefit management companies To make it available to insurance so they’re I think one of the things that we have to look at both the state and federal Level is how do we I mean, it’s going to be crazy to say this But how do we deregulate these medications so that they can be made widely available? to UM To people that need them because there’s a there’s a bottleneck at that level as well So it’s very hard to get people into our treatment like I said It’s much easier to get heroin that is going to drug treatment, and we need to sort of change that Okay so in terms of so Sai Provost, that’s a great name ask How do we advocate for more treatments is it lack in terms of beds or funding so I think? There’s a lack you know what would have been great to hear from the president yesterday is You know here’s a pot of money for evidence-based treatment States can draw on it as rapidly as they can get patients into these kinds of evidence-based treatments So there’s a money problem, and then on the other side. There’s a regulatory problem One thing I did mention is you know folks don’t and maybe in your own communities You’ve seen this people don’t like having methadone clinics around them, so they can be hard to cite Part of the advantage of the buprenorphine medications is that they’re designed to be given out by primary care physicians So you don’t end up generating the NIMBYism piece But there are still barriers to making Buprenorphine widely available, but but yeah, we need more money we need physician attention and willingness to address this problem we need Folks to understand all the multiple barriers to drug treatment entry that they have I mean another issue That’s occurring in the population I see is that generally speaking methadone doesn’t have a great reputation among heroin users and Many people think of buprenorphine is very similar to methadone and in fact it it actually isn’t In that it’s a longer act longer acting it has much less abuse potential or diversion potential For naive people, and it doesn’t have it has what’s called respiratory ceiling effect, so It is it’s a pretty protective against overdose so you know figuring out the policy solutions that allow a Lot of these medications to be prescribed through insurances and paid for and then dealing with the sort of barriers to use Among people with with the substance use problems. It would be another thing to look at So can we abuse of treatment yes, so we need more treatment all right, let’s see Jennifer yang Yeah more integrative key care team sure that’s not but that’s not a bad idea but I do want to emphasize again what I see so if we go back to the slide where I presented the demographic characteristics of the population 80% homeless right so we need a system of care for them That’s going to make it easy for homeless people homeless chronic drug users to get the health care They need so it’s less of an issue of when they get into the system is if you integrate it That’d be great but we can’t get them into the system at all and So there’s a lot of untreated people who I know from my many years of doing this work would be happy to receive treatment We just make it really hard for them to get it and and so we really need to rethink How we provide care to this population and think about it in terms of what are the lowest? What’s the lowest? Easiest way we can make it for them to get these life-saving medications So I think I’ve the questions that have been listed are there are others I Don’t see any other dr. Blumenthal, so thank you so much for answering all of those questions for us this afternoon I want to thank you Ricky Bluthenthal, I would like to thank Dr Shubha Kumar as well as Caroline for joining us today And I’d also like to thank everyone who participated in today’s webinar If you have any additional questions, or you know as a prospective student if you think that it’s time to apply Please reach out to either myself or one of our other advisors a copy of this recording and our slide presentation This definitely concludes today’s webinar, and I want to thank you again for joining and you all have a wonderful rest of the day


  • Reply ken seymour October 15, 2019 at 12:45 pm

    What did think was going to happen giving people large amounts of pain meds then just take them away if people just knew how bad the withdrawals are not just the withdrawal the length of post acute withdrawals which can last for months. Decriminalize drugs give people a safe alternative than go to a drug dealer

  • Reply ken seymour October 15, 2019 at 12:53 pm

    I wish you was in charge of the policy making something has to give just calling it a crisis and cut people off is not the way to help long term opioid use don’t just go away because the president think he can pat himself on the back because e declared it a crisis if it’s a disease which I believe it is why do they lock people up for disease what’s next lock cancer patients up for having cancer news flash many people that use heroin want off but they go to get it to treatment and they can’t afford it or there’s no open spots for 6 months

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