So first, we're going to talk about opioid use disorder in this module. In this lecture, we're talking about basically what is Opioid Use Disorder, and we're going to start off with opioid basics. So Opioids 101. What are Prescription Opioids? Prescription opioids can be prescribed by doctors to treat moderate to severe pain, but of course these opioids also have serious risks and side effects. Some common types, you've probably heard of these oxycodone or OxyContin, hydrocodone or Vicodin, sorry morphine and methadone. Heroin as an illegal opioids, and the use of heroin has increased across the United States among men and women, most age groups and all income levels. You've probably heard of Fentanyl in the news, Fentanyl is a synthetic opioid pain reliever. It is many times more powerful than other opioids. It's approved for treating severe pain, typically advanced cancer pain. Illegal fentanyl has been on the rise as have overdose deaths. Basically, what's happened is that gangs in other countries have figured out how to illegally manufacture fentanyl and smuggle into the US and sell in the black market. Because of that, we've seen a rapid rise in overdose deaths. So more basics. Note that I'm using the term opioid, which refers to both natural and synthetic substances that act at one of the three main opioid receptor types. The three receptor types are mu, kappa, and delta opioid receptors. Opioids can have analgesic and central nervous system depressant effects as well as the potential to cause euphoria. Opiate, and here refers to a subclass of opioids consisting alkaloid compounds that occur naturally opium poppy. These include morphine and codeine. Heroin, on the other hand, is the derivative of morphine, and is the opioid most commonly abused by injection. That chemical name for heroin is diacetylmorphine. Synthetic opioids are things like oxycodone and hydrocodone, which are semi-synthetic. Other full-blown synthetic opioids include fentanyl, tramadol and methadone. So what is opioid use disorder? About 2.1 million Americans had or met criteria for opioid use disorder in 2016. Opioid use disorder is defined in the DSM-5 as a problematic pattern of opioid use leading to clinically significant impairment or distress. Opioid use disorder was previously classified as opioid abuse or opioid dependence, and that was in the manual that came before the DSM-5 or the DSM-IV. So opioid use disorder is defined as having two or more of the following symptoms within 12 months. So this is the list of symptoms here. Using larger amounts of opioids or using them over a longer period of time was intended, persistent desire to cut down or unsuccessful attempts to control use, great deal of time spent obtaining or using or recovering from use, craving or strong desire or to use, failure to fulfill major role obligations because of opioid use, continued use despite recurrent or persistent social or interpersonal problems. Giving up on or getting up or reducing social occupational or recreational activities. Recurrently using in hazardous situations. Continuing to use despite physical or psychological problems. Tolerance, which basically means an increase in the amount of the drug to get the same effect, or it means you're getting less of an effect with the same amount of the drug. Withdrawal syndrome which is manifested by cessation of opioids and basically to relieve or avoid withdrawal symptoms. So couple of important notes about opioid use disorder, tolerance and withdrawal criteria are not considered for those taking opioids solely under appropriate medical supervision. Severity of opioid use disorder is categorized as mild if there only two to three symptoms, moderate if there are four to five symptoms, or severe if they're six or more symptoms. So what is the opioid epidemic in the United States and where does it come from? Well, in the late 1990s, pharmaceutical companies assured the medical community that patients would not become addicted to opioid pain relievers. Consequently, healthcare providers began to prescribe opioids at greater rates is corresponded with of course the increase in chronic pain. Increased prescription of opioid medications basically then began to lead to widespread misuse of both prescription and non-prescription opioids. It later became crystal clear that these medications could be highly addictive. So that was the genesis, the start of the opioid crisis. Just to give you some statistics in terms of how bad it is, roughly 21-29 percent of patients prescribed opioids for pain in that misusing them, between 8-12 percent will develop an opioid use disorder, between four and six percent who misuse prescription opioids eventually transitioned to heroin. But 80 percent of people who use heroin first misuse prescription opioids. Opioid overdoses increased to 30 percent from July 2016 through September of 2017 just like, just a little bit more than a year increased 30 percent. This is specifically in 52 areas in 45 states. So in some parts of the country, it basically shot up between 2016/2017. The Midwest saw opioid overdoses increased 70 percent during a similar time frame. Opioid overdoses in large cities increased by 54 percent in 16 states. So we have seen a rapid increase in the problem with respect to the epidemic in the middle of 2016/2017. So in 2017, we had over 70,000 drug overdose deaths in the US. Opioids, mainly synthetic opioids other than methadone, were the main driver of drug overdose deaths. So opioids were involved in about 47,600 deaths out of the 70,200 deaths. There's also a 30 percent increase in emergency department visits for overdoses, and people who have had at least one overdose are more likely to have another. This is an info graphic put up by Health and Human Services, which declared a public health emergency and announced a five-point strategy to combat the opioid crisis. But this basically scheduling is just on the same stats I gave you before in addition to other ones that really highlight the depth and breadth of this problem. So what else is being done about the opioid crisis? Well, in April 2018, the director of the National Institutes of Health, Francis Collins, announced the launch of the HEAL Initiative. Heal is Helping to End Addiction Long-term. It's an aggressive trans agency effort to speed up scientific solutions to basically stop this national opioid epidemic. HEAL will bolster research across NIH to improve treatment for opioid use disorder, and also to address the chronic pain issue. So some risk factors for opioid use disorder and overdose. Risk factors for opioid use disorder include things like past or current substance abuse problems, untreated psychiatric disorders, being younger, and social or family environments that encourage misuse. Risks factors for overdose include being middle aged, having other substance abuse issues or psychiatric comorbidities, and sometimes suicides are actually misclassified as opioid overdose deaths. Other risk factors for opioid use disorder include consuming high daily doses of prescribed opioids even after just a few days a consistent use. Living in rural areas. So people who live in rural areas are more at risk. Part of the thing that goes along with that is high rates of unemployment, poverty and lower education, and having chronic pain is risk factor, and being on Medicaid is a risk factor. Then being prescribed opiates for postoperative pain relief, some patients basically continue to fill prescriptions long after what would be considered normal for recovery period, and that can be a problem too. Strategies for prevention of opioid use disorders. Somethings that have been put in place in the last couple of years prescription drug monitoring programs to monitor the prescription of opioids. State prescription laws. [inaudible] management strategies and insurance programs that basically require prior authorization, limit quantities, and so forth educate providers about opioid prescribing guidelines. Facilitating conversations with patients about risks and benefits of other pain treatment options. Quality improvement programs in health care systems to increase implementation of recommended prescribing practices. Of course, patient education on safe storage and disposal a prescription opioids. So one of the first things that President Trump did was to put together this commission on combining drug addiction and opioid crisis. Chris Christie, former governor New Jersey was the chairperson. So they produce this report in 2017 and the conclusions that were relevant to Cannabis are as follows. They concluded that there was no evidence suggesting that cannabinoids might play a beneficial role in the opioid epidemic. They found no evidence regarding safety and efficacy of cannabis for pain. They found that the dangers of cannabis products outweighed any potential benefits in terms of pain or the opioid epidemic, and they found that cannabis use leads to opioid abuse. So it's just fascinating to see these conclusions given what we know about the science of cannabinoids. So summary for this lecture, the opioid epidemic is a big problem, 50,000 people are dying right now from year-to-year. You're now statistically more likely to die from an opioid overdose than a car accident, and that's pretty sad. Twenty five percent of those people who are prescribed opioids will misuse them, 10 percent of those who misuse will develop an opioid use disorder, five percent will transition to heroin, 80 percent of those who use heroin basically started by abusing prescription opioids. Natural resources had been mobilized and sadly that the President's Commission found that cannabis is dangerous and likely to make the problem worse. Of course, we will address cannabis in the upcoming lectures.
