Realities of addiction_volkow-final

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National Rx Drug Abuse Summit, April 2-4, 2013, General Session presentation "Realities of Addiction," by Dr. Nora Volkow, Director, National Institute on Drug Abuse

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Realities of addiction_volkow-final

  1. 1. Reali&es  of  Addic&on  Dr.  Nora  Volkow  April  2  –  4,  2013  Omni  Orlando  Resort    at  ChampionsGate  
  2. 2. Learning  Objec&ves  1.  Iden=fy  recent  increasing  trends  in  the  misuse  and  abuse  of  prescrip=on  drugs.  2.  Describe  the  ways  in  which  the  most  commonly  abused  prescrip=on  drug  classes  affect  the  brain  and  body.  3.  Explain  strategies  being  developed  and  implemented  that  will  increase  awareness  of  the  growing  problem  of  addic=on.  
  3. 3. Disclosure  Statement  •  Dr.  Nora  Volkow  has  no  financial  rela=onships  with  proprietary  en==es  that  produce  health  care  goods  and  services.  
  4. 4. Nora D. Volkow, M.D.Director
  5. 5. Numbers in Millions Prescrip&on  Drug  Misuse/Abuse  is  a  Major  Problem  in  the  US  Current  Drug  Use  Rates  in  Persons  Ages  12+  Source:    SAMHSA,  2011  Na2onal  Survey  on  Drug  Use  and  Health`  
  6. 6. Prevalence of Past Year Drug Use Among 12th graders2012 Monitoring the Future Study* Nonmedical useDrug   Prev.   Drug   Prev.  Tranquilizers*       5.3  Marijuana/Hashish   36.4   Hallucinogens   4.8  Small  Cigars   19.9   Seda&ves*     4.5  Hookah   18.3   Salvia     4.4  Synthe=c  Marijuana   11.3   OxyCon&n*     4.3  Snus   7.9   Hall  other  than  LSD   4.0  Narco2cs  o/t  Heroin*   7.9   MDMA  (Ecstasy)     3.8  Amphetamines*   7.9   Inhalants     2.9  Adderall*     7.6   Cocaine  (any  form)     2.7  Vicodin*   7.5   Ritalin*     2.6  Cough  Medicine*     5.6   LSD   2.4  Categories not mutually exclusive
  7. 7. 0100200300400500600700800900100011000 1 2 3 4 5 hrTime After Amphetamine%ofBasalReleaseAMPHETAMINE0501001502000 60 120 180Time (min)%ofBasalReleaseEmptyBox FeedingDi Chiara et al.FOODVTA/SNnucleusaccumbensfrontalcortexThese prescription drugs,like other drugs of abuse(cocaine, heroin, marijuana)raise brain dopamine levelsDopamine Neurotransmission Why Do People Abuse Prescription Drugs?
  8. 8. Opioids: Examples: OxyContin, VicodinAttach to opioid receptors in thebrain and spinal cord, blockingthe transmission of pain messagesand causing an increase in theactivity of dopamineHow They Work…•  Postsurgical pain relief•  Management of acute or chronicpain•  Relief of coughs and diarrheaOpioids are Generally Prescribed for:Amydala(reward)NAc(reward)Thalamus(pain)
  9. 9. Similari&es  Between  Illicit  and  Prescrip&on  Drugs  
  10. 10. StimulantsEnhance brain activity by increasing the activity ofbrain excitatory chemical messengers, such asnorepinephrine and dopamine, leading to mentalstimulationExample: RitalinHow They Work…•  ADHD•  Narcolepsy•  Depression that does notrespond to other treatments•  Asthma that does notrespond to other treatmentStimulants Are Generally Prescribed For:
  11. 11. MethamphetamineAdderallSimilari&es  Between  Illicit  and  Prescrip&on  Drugs  
  12. 12. •  Expectation of Drug EffectsExpectation of clinical benefits vs euphoria high•  Context of AdministrationSchool, clinic, home vs bar, discotheque•  Dose and Frequency of DosingLower, fixed regimes vs higher, escalating use•  Route of AdministrationOral vs injection, smoking, snortingWhat is the Difference BetweenTherapeutic Use and Abuse?
  13. 13. "High"   "High"  0204060801000204060801000 10 20 30 40 50 60 70 80%Peak[11C]CocaineTime (min)[11C]Methylphenidate0 10 20 30 40 50 60 70 80Rewarding Effects Depend on How Fastthe Drug Gets into the Brain
  14. 14. 00.010.020.030.040.050.060 20 40 60 80 100 120UptakeinStriatum(%/cc)Time (minutes)00.010.020.030.040.050.06UptakeinStriatum(%/cc)00.00050.0010.00150.0020.00250.0030.00350 20 40 60 80 100 120UptakeinStriatum(nCi/cc)Time (minutes)iv cocaine iv Ritalin oral RitalinRate of Drug Uptake Into the BrainCocaine (iv) and Ritalin (iv) produce a highbut Ritalin (oral) does not.The slow brain uptake of oral Ritalinpermits effective treatment without a high.0 20 40 60 80 100 120Time (minutes)Fast!!!Fast!!! Slow!!!
  15. 15. Source:  Volkow,  ND  et  al.,  Journal  of  Neuroscience,  23,  pp.  11461-­‐11468,  December  2003.  Glucose  Metabolism  Was  Greatly  Increased  By  the  Expecta2on  of  the  Drug      Unexpected MP700µmol/100g/minExpected MPIncreases  in  Metabolism  Were  About  50%  Larger  When  MP  Was  Expected  Than  Unexpected  051015202530%ChangeUnexpected  MP  Expected  MP  Expected  MP  Got  Placebo  
  16. 16. What  Has  Raised  Our  AUen2on  to  the    Problem  of  Prescrip2on  Drug  Abuse?    
  17. 17. Source: SAMHSA Treatment Episode Data Set(TEDS), 2000-201028,32637,64945,88252,66460,82471,04882,35998,386122,185142,124157,171020,00040,00060,00080,000100,000120,000140,000160,000180,0002000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010More Than 5-Fold IncreaseIn Treatment Admissions ForPrescription PainkillersIn the Past Decade12  10  8  6  4  2  0   1990          1992          1994          1996          1998        2000          2002          2004          2006          2008  *Deaths  are  those  for  which  poisoning  by  drugs  (illicit,  prescrip=on,  and    over-­‐the-­‐counter)  was  the  underlying  cause.Drug  Overdose  Death  Rates    in  the  US  Have  More    Than  Tripled  since  1990  Na&onal  Vital  Sta&s&cs  System.      Drug    Overdose  Death  Rates  by  State  2008.  100  people  die  from  drug  overdoses  every  day  in  the  US  
  18. 18. 35,00030,00025,00020,00015,00010,0005,0000Number  of  ED  Visits  9,0006,0003,0000Aged  5  to  11   Aged  12  to  17   Aged  18  to  25   Aged  26  to  34   Aged  35  or  Older  2005  2010  3,322  3,791  2,702  3,461  2,131  8,148  1,754  6,094  2,519  7,957  Number  of  ED  Visits  2005                                          2006                                        2007                                        2008                                          2009                                          2010  4,315  6,332  11,390   11,448   12,208  14,068  17,174  14,503  12,287  14,979  10,614  9,059  13,379  16,948  26,369  23,735  26,711  31,244  All  Males  Females  Emergency Department (ED) Visits Related toStimulant MedicationsSource:  SAMHSA  Dawn  Report:Emergency  Department  Visits  Involving  AUen2on  Deficit/  Hyperac2vity  Disorder  S2mulant  Medica2ons  ,  January  24,  2013.    
  19. 19. Data in Several States Show That Hepatitis C VirusAmong Adolescents and Young AdultsHas Increased in Recent YearsOf  cases  with  available  risk  data,  injec2on  drug  use  (IDU)  was  the  most  common  risk  factor  for  HCV  transmission    Although  only  a  small  number  of  these  cases  responded  to  further  inves2ga2on…..  •     92%  reported  opioid        analgesic  abuse    •     89%  reported  heroin  use  •     95%  used  opioid  analgesics          before  switching  to  heroin  •     During  the  preceding  6  months,          the  most  frequently  injected          drugs  were  heroin  (50%)        and  opioid  analgesics  (30%)  CDC, MMWR, May 6, 2011/60(17); 537-541;CDC,  MMWR,  October  28,  2011/60(42):1457-­‐1458  
  20. 20. Number of Opioid Prescriptions Dispensed byU.S. Retail Pharmacies, Years 1991-201176 78 8086 91 96 100109120131139144151158169180192201 20221021905010015020025091929394959697989920000102030405060708091011Prescriptions(millions)IMS’s Source Prescription Audit (SPA) &Vector One®: National (VONA)Opioids Hydrocodone Oxycodone
  21. 21. Oxycodone and Hydrocodone Prescriptions1998-2012Codeine & Comb NON-INJ (USC 02232), Morphine & Opium NON-INJ(USC 0222), Morphine & Opium INJ (USC 02221), Codeine & Comb INJ(USC 02231).Source: SDI Health, VONA16 19 22 25 27 29 31 34 38 43 47 49 54 57 5772839096 101 106 110120126132 133 130 131 136 1340204060801001201401601998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012MillionsOxycodone (Schedule II)Hydrocodone (Schedule III)
  22. 22. Opioid Prescriptionsby Age261930159-20406080100120140160180-51015202530352002 2006 2009 2012No.ofPrescriptions,Age40+(millions)No.ofPrescriptions(millions)0 to 9 10 to 19 20 to 2930 to 39 40+IMS Health, Vector One® NationalOpioids OverdoseDeath by Age Group,US, 2008Rate  per  100,000  Paulozzi LJ, J Safety Res 2012; 43(4):283-289.
  23. 23. 20%  15%  11%  10%  9%  27%  12%  11%  8%  5%  20%  16%  11%  9%  6%  20%  13%  9%  8%  7%  16%  12%  7%  6%  3%  0   0.1   0.2   0.3  Percentage of Prescriptions Dispensed for Opioid Analgesics fromOutpatient US Retail Pharmacies, by Age Group2006200222%  16%  11%  10%  8%  27%  12%  11%  8%  5%  19%  18%  12%  8%  7%  24%  12%  10%  8%  7%  26%  17%  9%  7%  4%  0   0.2  0 to 910 to 1920 to2930 to 39≥40EN PhysPediatricianDentistEmergMedGP/FM/DOOrthoSurgOB/GYNInternMedAnesthesIMS Health, Vector One®National23%  16%  13%  11%  6%  29%  12%  8%  8%  6%  17%  16%  13%  8%  8%  21%  10%  9%  8%  7%  25%  16%  7%  6%  6%  -­‐10%   10%   30%  2012
  24. 24. Top Prescribers of Opioid Analgesics in2012010,000,00020,000,00030,000,00040,000,00050,000,00060,000,00020022003200420052006200720082009201020112012PrescriptionsGP/FM/DOInternal medicineDentistryOrthopedicSurgeryIMS Health, Vector One® National
  25. 25. Percent  Source:  2010  Na2onal  Survey  on  Drug  Use  and  Health,  SAMHSA  2011.  Source  of  Prescrip&on  Drugs    (how  they  obtained  the  drugs  they  most  recently  used  nonmedically)   Rates  averaged  across  2009  and  2010  
  26. 26. Jones, CM et al. JAMA, February 20, 2013; 309(7): 657-659.National Center for Health Statistics show drug overdose deathsincreased for the 11th consecutive year in 2010In  2010,  there  were  38,329  drug  overdose  deaths  in  the  United  States  Percentage  of  Overdose  Deaths  for    Specific  Psychotherapeu=c  and    CNS  Pharmaceu=cals  that  Involved  a  Single  Drug  Class,  US,  2010    PsychotherapeuticandCNSPharmaceuticals,%Opioid    Analgesics  (n=16,651)  An&epilep&c  &  An&parkinsonism  Drugs  (n=1,717)  Benzodizepines  (n=6,497)  Barbiturates  (n=296)  An&depressants  (n=3,889)  An&psycho&c  &  Neurolep&c  Drugs  (n=1,351)    Other  Psychotropic  Drugs  (n=24)  35302520151050
  27. 27. Jones, CM et al. JAMA, February 20, 2013; 309(7): 657-659.PERCENT      Drug  Involvement  in  Pharmaceu=cal  Overdose  Deaths          Opioid  Analgesic  Involvement  in  Deaths  for  Specific  Drugs  Specific  Drug  Involvement  in  Pharmaceu&cal  Overdose  Deaths  USA,  2010  75.27.829.41.317.66.10.110065.577.25057.6 5854.2020406080100120
  28. 28. How to Minimize the Diversion andAbuse of Prescription MedicationsEngage the Healthcare System
  29. 29. Doctors Need to Know…What Opioid Prescriptions Have Been Given toTheir Patients By Other Doctors or PractitionersThis information should be:1)  included in the patients’electronic health care records2)  accessible through aPrescription Drug MonitoringProgram (PDMP) that providesimmediate information and cancross-reference across States
  30. 30. Mezei,  L  and  Murinson,  BB.,  J  Pain,  12,  1199  -­‐1208,  2011.  Education on Pain in Medical SchoolsNumber of Hours of Pain EducationNumber  of    Schools  USA (median: 7 hours)Canada (median: 14 hours)Veterinarian schools:75 hours on pain0-5 5-10 10-15 15-20 20-25 25-30 >30
  31. 31. •  Centers of Excellence in Pain Education (12 CoEPE)•  Consensus Workshop on Opioidsfor Chronic PainICs Involved:ORWH NIAOBSSR NINRNIDA NICHDNIDCR NIAMSNINDS NCCAM
  32. 32. •  Efficacy of opioids for treating chronic pain•  How to administer opioids for optimal efficacy and minimaladverse effects•  Risks for addiction•  Populations differences•  What training is available (other than offered by industry) forteaching how and what type of opioids should be used inmanaging chronic pain?•  What research directions need to be pursued to determine bestapproaches for managing chronic pain with opioids?•  For research gaps, what are research priorities?Consensus Workshop: Opioids for Chronic Pain
  33. 33. Prevention Strategies – Public EducationCME Courses developed by NIDA & Medscape Education, funded by ONDCPSafe  Prescribing  for  Pain  Managing  Pain  Pa&ents    Who  Abuse  Rx  Drugs  Skills  and  tools  clinicians  can  use  to  screen  for  and  prevent  abuse  in  pa7ents  with  pain      Learn  symptoms  of  opioid  addic7on  and  dependence  in  pa7ents  with  chronic  pain,    and  how  to  screen  for,  prevent        and  treat  such  condi7ons    
  34. 34. Pain  Medica&ons    •  Develop medications with slower abusepotential including drugs that don’t crossBBB (i.e., CBR2 agonist)•  Develop slow release formulations (lowdose and long duration)•  Develop novel formulations toreduce abuse liability includingmixture formulations (e.g., naloxoneand buprenorphine)00.00050.0010.00150.0020.00250.0030.00350 20 40 60 80 100120UptakeinStriatum(nCi/cc)Time (minutes)Slow!!!
  35. 35. Prevention Strategies – Overdose Intervention•  Naloxone Distribution for opioidoverdose victims. The potential fordirect intervention to save lives.•  Naloxone Nasal Spray DevelopmentNeedle-free, unit-dose, ready-to-useopioid overdose antidoteNIDA  STTR  Grantee  –  An7Op,  Inc.,  Daniel  Wermeling,  CEO    Contact:  E-­‐mail:  dpwermeling@gmail.com,  Tel:  859-­‐221-­‐4138  
  36. 36. Treatment of Addiction to Prescription OpioidsBuprenorphineCurrently  19,000  physicians  are  certified  to  prescribe  buprenorphine  (Source:  CSAT  Buprenorphine  Information  Center)  Targets the same opioid receptors asmorphine (mu) but its much less potent,has a much longer half life and does notproduce the same high as heroin ormorphine
  37. 37. Universal Drug Abuse PreventionMay Reduce Prescription Drug MisuseSpoth et al., Addiction 2008;103(7):1160-1168.Spoth, et al., AJPM 2011;40(4):440-447For 100 young adultsin general populationstarting Rx abuse,only 35 young adultsfrom an interventioncommunity started.Overall, three studiesnow suggest theimpact of universalprevention onprescription drugabuse.
  38. 38. www.drugabuse.gov
  39. 39. Numbers  in  Thousands  Source:  2011  Na2onal  Survey  on  Drug  Use  and  Health,  SAMHSA,  2012.  Large Number of Past Year Initiates of Pharmaceuticals:Persons Aged 12 or Older, 2011MarijuanaPain RelieversTranquilizersEcstasyInhalantsCocaineStimulantsLSDHeroinSedativesPCP
  40. 40. Overdoses of prescription painkillershave more than tripled in the past 20years, killing more than 15,500 people inthe US in 2009For  every            overdose  death  from  prescrip=on  painkillers    there  are  treatment  admissions  for  abuse  emergency    department  visits  for  misuse  or  abuse  people  who  abuse  or  are  dependent  people  who  take  prescrip=on    painkillers  for  non-­‐medical  use  10  32  130  825  

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