An NASW Online Webinar Series Presented by: Dr. Joseph Hunter, LCSW, Ph.D. 1. Introduction and Problem Overview 2. Etiology: Genetics, Neurobiology and Psychosocial Factors 3. Co-Occurring Disorders 4. Levels of Care, Addiction Medicines and Therapies 1. Participants will learn the incidence and prevalence of opiate addiction, as well as trends nationally and in New York State. 2. Participants will learn the risk and protective factors associated with opiate addiction. 3. Participants will learn how opiate addiction is similar to other addictions, but also how it is uniquely different in many ways. 4. Participants will learn about the sources of opiates, the nomenclature associated with the various forms of the substance, and the various ways it is misused and abused. What do you hope to gain from this webinar today? Please write this on your worksheet and post it in the chat (if you wish) Although I am an employee of both Veterans Affairs (VA) and The University of Southern California (USC), this presentation is done independently of those positions.

The views expressed in this presentation are those of the author and do not necessarily reflect the opinion, position or policy of the VA, the US Government or USC.

In addition, although I am recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers (#324), this training is offered under NASW’s approved provider number. Mark is a 21-year-old Caucasian male who is using heroin daily, following a long period of abusing prescription opiates - his own, his parents and those he bought ”from the streets.” He played soccer during high school, but seriously injured his knee during his freshman year in college, which is when he was first exposed to opiates. Previously, he had been binge drinking alcohol on the weekends and using cannabis monthly. 61.8 million smoked cigarettes 175.8 million people drank alcohol 36.0 million people used marijuana 4.8 million people used cocaine 828,000 people used heroin 1.5 million people used lysergic acid diethylamide (LSD) 2.6 million people used Ecstasy 1.8 million people used inhalants 1.7 million people used methamphetamine [compare to 12.5 million misusers of prescription pain killers]

Suicide: 44,193 Unintentional Poisoning: 44,126 Motor Vehicle Accident: 37,757 Homicide: 17,793 Drug overdose is the leading cause of accidental death in the US 52,404 lethal drug overdoses in 2015 Opioid addiction is driving this epidemic 20,101 overdose deaths on prescription pain relievers 12,990 overdose deaths on heroin in 2015 Opium: A fluid obtained from the poppy plant Opiate: A substance derived from opium Opioid: A substance with morphine-like actions, but not derived directly from the poppy plant Papaver Somniferum “Poppy Plant” Poppy Plant Morphine , 4 - 21 % Codeine, 1 - 25% New “No-Morphine” plant called TOP1 or Normano Thebaine and Oripavine produce higher concentrations 4000 – 2000 BC: Opium was believed to be discovered in the Mediterranean area 1500 BC: Egyptian papyri list opium as one of 7000 remedies 1st century AD: Opium poisoning described 1655: Portuguese physician, Acosta, wrote of withdrawal sickness 1701: British physician, John Jones, advocated moderation in the use of the drug in order to avoid the discomforts with its continued use 1805: Morphine isolated as the main active ingredient in opium 1850 – 1865 thousands of Chinese laborers immigrated to the US and brought the habit of opium smoking with them Civil war soldiers became opioid dependent through medical treatment – referred to as “army disease” or “soldier’s disease” It was estimated that the total number of opium users in the U.S. in 1868 was 100,000 (<63 million US population at the time) Heroin was first synthesized in 1874 by the chemist, C.R. Alder Wright First commercial production in 1898 by the Bayer Pharmaceutical Company 1898: Heinrich Dreser announced that tests confirmed heroin was ideal for treating bronchitis, emphysema, asthma and tuberculosis Also, a cure for opium and morphine dependence  Heroin is an opioid drug that is synthesized from morphine  Heroin usually appears as a white or brown powder or as a black sticky substance, known as “black tar heroin.”  A “stamp-bag” of heroin (roughly one hit or 0.1 grams) can cost as little as $5 in some parts of NYS.  Smack  Black pearl  China white  Dope  Brown sugar  Boy  Mud  Witch hazel  Chiva  Horse or H  Birdie  Mexican  Skag powder horse  Junk  Dragon  Pluto  Thunder  Hero  Skunk  Black tar  White stuff  Number 2

An increase in purity led to an increase in the number of heroin users in the United States When heroin is higher in purity, it can be snorted or smoked, which broadens its appeal Many people who would never consider injecting a drug were introduced to heroin by inhalation. In the 1990s, the drug largely lost the stigma associated with injecting, and a new population of heroin users emerged. Inhalation remains a common method of administration by new heroin initiates. This new population of users is more diverse. Whereas in the 1970s and 1980s heroin use was largely confined to urban populations, heroin use in the 1990s and 2000s spread to users in: suburban and rural areas more affluent users younger users users of a wider range of races There is no longer a typical heroin user Mexican traffickers have taken a larger role in the U.S. heroin market, increasing their heroin production and pushing into eastern U.S. markets The previous two decades were largely supplied by Colombian traffickers. This is notable because Mexican traffickers control established transportation and distribution infrastructures that allow them to reliably supply markets throughout the United States. Heroin, while used by a smaller number of people than other major drugs, is much more deadly to its users The population that currently uses prescription pain relievers non-medically was approximately 15 times the size of the heroin user population in 2013  However, opioid analgesic-involved overdose deaths in 2013 were only twice that of heroin-involved deaths. Current cocaine users outnumbered heroin users by approximately 5 times in 2013, but heroin-involved overdose deaths were almost twice those of cocaine. Deaths involving heroin are also increasing at a much faster rate than for other illicit drugs

Prescription drug misuse is second only to marijuana use as the nation's most common type of illicit drug use. The prevalence of and reasons for prescription drug misuse has major public health implications.

AGAIN

18.9 million people aged 12 or older (7.1 percent) misused prescription psychotherapeutic drugs in the past year. 12.5 million people who misused pain relievers in the past year (4.7 percent) 6.1 million who misused tranquilizers (2.3 percent) 5.3 million who misused stimulants (2.0 percent) 1.5 million who misused sedatives (0.6 percent) 84.1 percent who used prescription drugs in the past year did not misuse them  Past year prescription pain medication misuse Men 5 million Women 4 million  Opiate and other Rx Drug misuse 12- 17 year olds: 6 percent 18-25 year olds: 12 percent 25 and older: 5 percent

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH), 2015. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH), 2015.

1 in 5 teens are abusing prescription drugs 70% of prescription drugs are obtained from a friend or relative 40% of teens believe prescription drugs are safer than illicit drugs Combining prescription drugs/over the counter medications and alcohol can cause respiratory failure and death After alcohol and marijuana, prescription drugs are the next most abused drugs among youth Approximately 1.4 million New Yorkers suffer from a substance use disorder Heroin overdose is now the leading cause of accidental death in NYS Between 2005 and 2014, upstate New York has seen a 222 percent increase in admissions to OASAS certified treatment programs among those 18 to 24 years of age for heroin and other opioids Long Island has seen a 242 percent increase among the same age group for heroin and other opioids

High purity batches of heroin sold in certain markets, causing users to accidentally overdose An increase in new heroin initiates, many of whom are young and inexperienced Abusers of prescription opioids (drugs with known compositions and concentrations) initiating use of heroin An illicitly-manufactured drug with varying purities, dosage amounts, and adulterants The use of highly toxic heroin adulterants such as fentanyl in certain markets. Those who relapse are particularly susceptible to overdose, because their tolerance for the drug has decreased

5% 12% 26% Bronx Kings New York 22% Queens Richmond 35%

Obtaining overlapping prescriptions from multiple providers and pharmacies Taking high daily dosages of prescription pain relievers Having mental illness or a history of alcohol or other substance abuse Living in rural areas and having low income Being addicted to prescription opioids, cocaine, marijuana or alcohol Being enrolled in Medicaid or being without insurance Non-Hispanic whites Males Those living in large metropolitan areas 18 to 25 year olds  Fentanyl is a Schedule II short-acting synthetic opioid that is often used to treat chronic pain. It is 25 to 40 times more potent than heroin and 50 to 100 times more potent than morphine by weight (DEA,2015b,2015c; NIDA,2012).  Fentanyl and fentanyl analogs are abused for their "intense, albeit short-term high and temporary feelings of euphoria" (DEA,2015c).  There were more than 700 overdose deaths related to fentanyl and its analogs nationwide from late 2013 through 2014,and the deaths have continued into 2015.  The true number is most likely higher because many coroners and crime laboratories do not test for fentanyl specifically, unless given a reason to do so.  Pharmaceutical fentanyl can be illegally diverted for abuse. It comes in a variety of forms, including patches, lozenges, tablets, and films (CDC,2015; DEA, 2015c).  Illicitly-produced, non-pharmaceutical fentanyl and fentanyl analogs, such as acetyl fentanyl, are emerging in the illicit drug market. They can be snorted or injected in powder form or swallowed as a pill (DEA,2015a, 2015b, 2015c).

Mark is a 21-year-old Caucasian male whose use of heroin progressed to daily use, following a long period of abusing prescription opiates - his own, his friends’ and parents,’ and those he bought ”from the streets.” Background: He played soccer during high school, but seriously injured his knee during his freshman year in college, which is when he was first exposed to opiates. He was given a 3-month, daily supply of oxycodone between the ED and his PCP. Prior to this opiate use, his substance use included binge drinking alcohol on the weekends and using cannabis twice monthly. He also smoked a pack of cigarettes daily. Mark’s desire to get high outlasted his supply of prescription medications, and he was able to find opiates from friends and family members for another 6 months. As getting high became a top priority in his life, his grades suffered and he dropped out of school junior year. His GPA dropped from a 3.3 average during freshman year to a 1.6 average during the first semester of junior year. He attempted to quit the opiate pills on his own several times; he also tried to substitute with alcohol, but the alcohol did not satisfy him, so he eventually turned to street heroin. Within 6 months of starting it, he had increased his use to 5 to 10 bags of heroin daily. He worked part- time delivering pizza to support this use. When he ran out of funding for his heroin, he would either borrow or steal from his grandmother, whom he helped with household tasks occasionally and who was unaware of his growing drug dependency. One day, his parents found Mark unresponsive on the couch in the basement in front of the TV, where he often spent his time. They called 911 and he was revived with Narcan; he was taken to the hospital and then admitted to a medically monitored detox. 1. Participants will understand how existing theories seek explain how opiate addiction starts, spreads and sustains its grip in the US population and local communities. 2. Participant will learn the neurological mechanisms of opiate addiction. 3. Participants will learn of the genetic, biological and epigenetic factors associated with opiate addiction.