Trends within Abuse and Healthcare – COVID and Beyond

Richard C. Dart, MD, PhD Director, Rocky Mountain Poison and Drug Safety, Denver Health Executive Director, RADARS® System Professor, University of Colorado School of Medicine Competing Interests

RADARS® System is the property of The Denver Health and Hospital Authority (DHHA), a political subdivision of the State of Colorado.

RADARS® System is supported by subscriptions from pharmaceutical manufacturers, government and nongovernment agencies for surveillance, research, and reporting services. No subscriber participated in the conception, analysis, drafting, or review of this presentation.

2 3 What Caused the US Crisis - HHS

• In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers and health care providers began to prescribe them at greater rates. • Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription before it came clear that these medications could indeed be highly addictive. • 2017 HHS declared a public health emergency and announced a five point strategy to combat the opioid crisis

https://www.hhs.gov/opioids/about-the-epidemic/index.html 4 What Really Happened?

• Health care systems and regulation • Fifth vital sign, patient “satisfaction,” etc. • Careless doctors • We knew better, but let convenience win out. • Criminal behavior • Opioid marketing • Aggressive, irresponsible • Increased supply of illicit opioids • Lack of treatment for OUD • Good, but after the fact, insufficient to meet demand • Increased demand?

5 What Happened to Rx Drug Abuse?

10 Years ago… Prescription drug abuse is the Nation's fastest-growing drug problem, and the Centers for Disease Control and Prevention has classified prescription drug abuse as an epidemic. … nearly one-third of people aged 12 and over who used for the first time in 2009 began by using a prescription drug non medically.

6 Real World Evidence and Triangulation RADARS® System Acute Substance Use Health Effects Treatment

Drug Population Diversion Survey

SUBSTANCE ABUSE

Street Price Web Discussion

Mortality

Lawlor DA, et al. Int J Epidemiology, 2016, 1866–1886 doi: 10.1093/ije/dyw314

7 Opioid Prescribing Decreased Until COVID

70000000 2020

60000000

Rx 50000000 Dispensed Total Opioid Rx 40000000 -36%

30000000 ?

20000000 Total ER Rx -53% 10000000

0

Source: IQVIA™ US-Based Longitudinal Prescription Data 8 RADARS Drug Diversion Program, 2006 - 2020

Diversion of Prescription Drugs 3

2.5 Invest. Opened 2 Per 100,000 1.5 population 1

0.5

0

Combined: , , , , ,

9 9 RADARS Drug Diversion Program, 2006 - 2019

1.2 3 2019 2019 Oxycodone 1 2.5 Fentanyl

2 0.8 Hydrocodone Invest. Opened Hydromorphone 1.5 0.6 Per 100,000 Morphine 1 0.4 population

0.5 0.2 Tramadol

Oxymorphone 0 0

oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, tramadol

10 10 Total Drug-Involved Deaths in the US

93,000

11 HOW CAN WE HAVE DECREASING PRESCRIPTION DRUG ABUSE, BUT INCREASING DEATHS?

12 13 Most Deaths are Due to Fentanyl and (Often Adulterated with Fentanyl or Analogs)

Fentanyl is the reason that deaths are increasing while Rx opioids are decreasing

13 Drug Exposure - – – Etc.

Risk Factors Risk Factors Family Dysfunction Physical Abuse Emotional Abuse Trauma Isolation Genetics Polysubstance Abuse

Opioid Sedative/Hypnotics Antipsychotic GABAergic • Heroin/Fentanyl • Alprazolam • Quetiapine • • Designer opioids • Diazepam • Olanzapine • • Rx analgesics • Designer drugs • Loperamide • Z-Drugs NPS/Synthetic • • • • • LSD • • • • Synth Cann’oids • Designer drugs

14 Drug Exposure Nicotine - Alcohol – Cannabis – Etc.

Risk Factors Risk Factors Family Dysfunction Physical Abuse Emotional Abuse Trauma Isolation Genetics Polysubstance Abuse

OpioidDrugs are notSedative/Hypnotics my problem. Antipsychotic GABAergic • Heroin/Fentanyl • Alprazolam • Quetiapine • Pregabalin • DesignerReality opioids is my• Diazepam problem. • Olanzapine • Gabapentin • Rx analgesics • Designer drugs • LoperamideDrugs are my• Z-Drugs solution. Stimulant Hallucinogen NPS/Synthetic • Cocaine • Ketamine • Mephedrone • Amphetamine • LSD • Cathinones • Methylphenidate Russell• Psilocybin Brand • Synth Cann’oids • Designer drugs

15 It’s Not the Drug

16 Deaths of Despair

TITLE OF YOUR PRESENTATION HERE 17 Strategy Implications • : “The ” • Better law enforcement can reduce the amount of drug available • No drug = no abuse • But efforts have failed for over 50 years • Demand reduction • If people don’t want to abuse drugs (e.g. no market for sale), then there will be no supply. • Community Coalitions • treatment facilities • • Measures to reduce the harm produced by drug abuse (e.g. needle exchange programs, take-home naloxone, etc.)

18 Project Lazarus

• Provider Education • Naloxone • Community Education • Pain Patient Support • Public Awareness • Pain Management • Hospital ED Policies • Data & Evaluation • Treatment • Harm Reduction • Diversion control • Legislation

19 https://www.projectlazarus.org/ Covid and Beyond

20 Treatment Center Programs, 2008 - 2020

1.6 2020 1.4

1.2

Endorse. 1 Per 100,000 0.8 population 0.6

0.4

0.2

0 20081 20084 20093 20102 20111 20114 20123 20132 20141 20144 20153 20162 20171 20174 20183 20192 20201 20204

oxycodone, hydrocodone, hydromorphone, morphine, tramadol

21 Treatment Center Programs, 2008 - 2020

1.6 1.2 2020 2020 1.4 1 1.2 Oxycodone 0.8 Hydrocodone Endorse. 1 Hydromorphone Per 100,000 0.8 Morphine population 0.6 Methdaone 0.6 0.4 0.4 Tramadol 0.2 0.2 Heroin Oxymorphone 0 0 20081 20084 20093 20102 20111 20114 20123 20132 20141 20144 20153 20162 20171 20174 20183 20192 20201 20204 20081 20084 20093 20102 20111 20114 20123 20132 20141 20144 20153 20162 20171 20174 20183 20192 20201 20204

oxycodone, hydrocodone, hydromorphone, morphine, tramadol

22 Changes in Treatment Center Operations

Operation Change March 1, 2020 June 1, 2020 October 1, 2020 through May 31, through through December 2020 September31, 2020 31, 2020

Suspended patients from entering 15.3% 3.1% 11.9% treatment Temporarily Closed 6.9% 3.1% 5.1% and Reopened No 76.4% 93.8% 83.1% closure/suspensions

23 Open Ended Text Response Examples

• “A decrease in the number of patients seeking MAT services” • “Moved to… two week or monthly take homes.” • “Telehealth counseling; car dosing” • “Staffing shortages have led to decreases in counseling services...” • “Due to court and legal offices not meeting regularly, demand for treatment has decreased.” • “Some clients who are positive for Covid or experience symptoms have been dosed in their cars.” • Several noted increased use of telemedicine for treatment and counseling

24 What Comes Next?

25 - Increasing Mortality over Time

Mortality related to medical stimulants is rising rapidly alongside illicit substances like cocaine and .

Black J, et al. Association of Medical Stimulants With Mortality in the US From 2010 to 2017 26 doi:10.1001/jamainternmed.2020.7850 Interaction of Licit and Illicit Pharmaceuticals

Illicit Licit

27 3 Million Adults Have Used Kratom, NMURx, 2018-2019

Estimated prevalence of lifetime Kratom use is 1.3% = 3,353,624 adults

50 45 Kratom (use in past year) 40 Prescription Opioid (non-medical use 35 in past year) Endorsed by 30 User (%) 25 20 15 10 5 0 None (0) Low (1-2) Moderate (3-5) Substantial (6-8) Severe (9-10)

DAST-10 Risk Category (Score Range)

Schimmel J, et al. Prevalence and description of kratom () use in the United States: A 28 cross‐sectional study. Addiction. 2020 https://doi.org/10.1111/add.15082. Nonmedical Use of Loperamide (Immodium) in UK and US, NMURx, 2017

Why?

100 80 UK 60 US 40 20 0 Tx Med Condit Get High Come Down Withdraw Other

Webb NE, et al. Non-medical use of loperamide in the UK and USA. QJM. 2020 DOI: 10.1093/qjmed/hcz215

29 Increasing Diversion of Nonscheduled Psychoactive Prescription Medications

Rx Opioids Flexeril Quetiapine Trazodone

Kurtz SP, et al. Pharmacoepidemiol Drug Safety, 2019 30 Summary

• Opioid deaths are still rising • Deaths mainly due to synthetic opioid analog • It’s Not Just The Drug • Most patients misuse more than one drug • Most deaths involve more than one drug • Treatment needs to address the underlying causes of opioid use • Abuse of other drugs is skyrocketing • Societal mirror?

31 Questions?

www.RADARS.org Is [email protected] Oxycodone Surging?

32 32