The Prescription Opioid and Heroin Crisis:
An Epidemic of Addiction
Andrew Kolodny, M.D.
Chief Medical Officer, Phoenix House Foundation Inc.
Executive Director, Physicians for Responsible Opioid Prescribing
Senior Scientist, Heller School for Social Policy and Management, Brandeis University
Research Professor, Global Institute of Public Health, New York University
The Opium Poppy
Papaver Somniferum
2
Opium
3
Opioids
•
•
•
•
•
•
•
•
Morphine
Naturally occurring opioidsCodeine
also called opiates
Thebaine
Diacetylmorphine (Heroin)
Hydrocodone (Vicodin)
Oxycodone (Oxycontin)
Oxymorphone (Opana)
Hydromorphone (Dilaudid)
Semi-synthetic
opioids
Unintentional Drug Overdose Deaths
United States, 1970–2007
10
Death rate per 100,000
9
43,982 drug overdose deaths in 2013
8
7
6
5
4
Cocaine
3
2
Heroin
1
0
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Year
National Vital Statistics System, http://wonder.cdc.gov
Drug Overdose Deaths by Major Drug Type,
United States, 1999–2010
Opioids
Heroin
Cocaine
Benzodiazepines
18,000
16,000
Number of Deaths
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
2009
2010
Opioid Related Overdose Deaths
United States, 1999-2013
Painkillers
Heroin
Total Opioid
26,000
24,000
22,000
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
Heroin admissions, by age group & race/ethnicity: 2001- 2011
8
Death rates from overdoses of heroin or prescription
opioid pain relievers (OPRs), by age group
SOURCE: CDC. Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012
MMWR. 2014, 63:849-854
9
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
10
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
11
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
12
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
13
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
14
Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)
15
Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011
16
Unintentional overdose deaths involving opioid
analgesics parallel per capita sales of opioid
analgesics in morphine equivalents by year,
U.S., 1997-2007
14000
*
800
12000
700
10000
600
8000
500
Number of
6000
Opioid sales
(mg/person)
Deaths
400
300
4000
200
2000
100
0
0
'97
'98
'99
'00
'01
'02
'03
'04
'05
Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS
* 2007 opioid sales figure is preliminary.
'06
'07
8
Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010
Opioid Sales KG/10,000
Opioid Deaths/100,000
2000
2003
Opioid Treatment Admissions/10,000
7
6
Rate
5
4
3
2
1
0
1999
CDC. MMWR 2011
2001
2002
2004
2005
Year
2006
2007
2008
2009
2010
19
20
Dollars Spent Marketing OxyContin (1996-2001)
Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and
Efforts to Address the Problem.”
Industry-funded “education” emphasizes:
• Opioid addiction is rare in pain patients.
• Physicians are needlessly allowing patients to
suffer because of “opiophobia.”
• Opioids are safe and effective for chronic pain.
• Opioid therapy can be easily discontinued.
23
Industry-funded organizations
campaigned for greater use of opioids
• Pain Patient Groups
• Professional Societies
• The Joint Commission
• The Federation of State Medical Boards
24
“The risk of addiction is much less than 1%”
Porter J, Jick H. Addiction rare in patients treated
with narcotics. N Engl J Med. 1980 Jan
10;302(2):123
Cited 824 times (Google Scholar)
25
N Engl J Med. 1980 Jan 10;302(2):123.
26
“I think that after 20 years of a failed
experiment that there are not many people
supporting this except for the die-hards and
the pharmaceutical industry.”
Jane C. Ballantyne, MD FRCA
Professor, Univ. of Washington
Source: New York Times, April 9, 2012. “Tightening the Lid on Pain
Prescriptions”.
The Emperor’s New Paradigm:
Patient Selection, Risk Stratification & Monitoring
29
Urine Tox Results in Chronic Pain Patients on Opioid Therapy
Source: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug
use in the chronic pain population. Popul Health Manag. 2009;12(4):185–190.
30
Controlling the epidemic:
A Three-pronged Approach
• Prevent new cases of opioid addiction.
• Treatment for people who are already
addicted
• Supply control- Reduce over-prescribing
and black-market availability.
31
How the opioid lobby frames the problem:
Source: Slide presented by Lynn R. Webster MD at FDA meeting on
hydrocodone upscheduling, January 25th, 2013.
Non-medical use (abuse) of painkillers declining since 2002
Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of
Addiction. Annu Rev Public Health. 2015: 36:559-574
33
Non-medical Opioid Users
Opioid Overdose Decedents
Source: Kolodny et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu
34
Rev Public Health. 2015: 36:559-574
This is a false dichotomy
Aberrant drug use behaviors are common in pain patients
63% admitted to using opioids for
purposes other than pain1
Pain Patients
“Drug Abusers”
35% met DSM V criteria for
addiction2
92% of opioid OD decedents
were prescribed opioids for
chronic pain.
1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving
Daily Opioid Therapy. J Pain 2007;8:573-582.
2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:
comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.
3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of
Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.
Summary
• The United States is in the midst of the
worst drug epidemic in its history.
• Ending the epidemic requires:
– PREVENTING new cases of opioid addiction
– TREATMENT for people who are already
addicted
36