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Collision of COVID-19 on Opioid Overdose and Treatment

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Collision of COVID-19 on Opioid Overdose and Treatment Emerging Issues in the Opioid Crisis Nora D. Volkow, M.D. Director National Institute on Drug Abuse @NIDAnews Overdose Deaths in 2019 Increased by 4.6% Number of Deaths Number of Deaths 40,000 Fentanyl, 37,137 18,000 Prescription opioids, 14,347 Methamphetamine, 16,539 35,000 16,000 Heroin, 14,278 Cocaine, 16,196 30,000 14,000 12,000 25,000 10,000 20,000 8,000 15,000 6,000 10,000 4,000 5,000 2,000 0 0 Overdose Death Rates: Other Synthetic Narcotics (Including Illicit Fentanyl) 2013 2018 Source: CDC WONDER. Age-adjusted death rates per 100,000. Overdose Death Rates: Psychostimulants With Abuse Potential (Including Methamphetamine) 2013 2018 Source: CDC WONDER. Age-adjusted death rates per 100,000. Intersection Between Opioid Crisis and COVID-19 ` Overdoses Grew Dramatically During COVID Pandemic ST Drug Use Increase During COVID Total US Increase 31.96% 19.96% 10.06% 12.52% 7 Millennium Health Signals Report™ COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic Volume 2.1 | Published July 2020 Total Study Population Change in Unadjusted Positivity Rate for Cocaine, Fentanyl, Heroin and Methamphetamine COVID-Related Policy Changes for Prescribing Medications for OUD Methadone Buprenorphine Prior to COVID: Prior to COVID: • Only federally-approved opioid • Prescribed through pharmacies in outpatient treatment programs settings • In-person for daily dosing • DATA 2000, limited to clinicians with bup. waivers that required additional training and Under COVID, SAMSHA allowed: federal registration • 3/16/2020: 28 day take home • Limited number of patients to treat • 3/20/2020: for those under • In-person evaluation for initial dose quarantine—surrogate take home or door-step delivery Under COVID, DEA allowed: • Still requires in person visit for first • 3/17/2020: Buprenorphine initiation through dose telehealth (including phone) without in- person visit • Follow up can be via phone Additional Opportunities in SUD Treatment Under COVID • Increased use of telemedicine and its reimbursement Expanded access to treatment of co-morbid conditions Expanded access to behavioral treatments Establishment of mental health hot lines Deployment of virtual support meetings and coaches • Changes in justice settings Release of non-violent offenders with SUD from jails/prisons Expanded use of telemedicine including for medications for OUD Expanded opportunities for education via web-based program U.S. Drug-Involved Overdose Deaths, by Race 30 AI/AN (NH), 27.0 25 White (NH), 25.7 Black (NH), 21.1 20 U.S. , 20.7 15 Hispanic, 11.0 10 Adjusted Rate/100K Population Rate/100K Adjusted - 5 Age Asian or PI (NH), 3.7 0 Includes all underlying causes of death: unintentional, intentional and undetermined. Medications Currently Available For Nicotine Addiction • Nicotine Replacement Therapies (NRT) • Bupropion • Varenicline For Alcohol Use Disorder • Disulfiram • Naltrexone • Acamprosate For Opioid Addiction • Methadone • Naltrexone • Buprenorphine Stimulant (cocaine and methamphetamine) Use Disorder Medication Pipeline Black – NME Red – New Indication Blue – Biologic Green – Gene Therapy * cocaine + meth * + cocaine or meth Early Preclinical Late Preclinical Ph I Ph Ib Ph II Ph III T2L: (>12 yrs) (10-12 yrs) (6-10 yrs) (5-9 yrs) (4-6 yrs) (3-5 yrs) SBI-0069330 or GLT-1 up-regulator * Orexin-1 dAdGNE * Mirtazapine * NS2359 * Mavoglurant * SBI-0801315 * + antagonist * Anti-cocaine vaccine NE/5HT antagonist DAT/NET/SERT inhib. mGluR5 mGluR2 PAM non-competitive antagonist NOP/Kappa/Mu Meth vaccine + IXT-m200 + Cocaine hydrolase Duloxetine & Bupropion * Lorcaserin * ligands * Long-duration gene therapy * Methylphenidate + DAT/NET inhibitor anti-meth mAb NET/SERT inh. & CNS stim. PTPRD ligands * + Cocaine hydrolase * Methamphetamine h2E2 * Lorcaserin * Adderall * EMB-001 * Conjugate Vaccine Anti-cocaine mAb 5-HT2C agonist Mixed amph. salts Metyrapone/oxazopam GC synth inhib/benzo. Peptidic KOR agonists * VMAT-2 inhibitor + Cariprazine * Ketamine * Guanfacine * D3/D2/5HT1A partial NMDA antag. α2A agonist agonist Pomaglumetad IXT-m200 + methionil + Anti-meth mAb mGluR2/3 agonist prodrug Clavulanic acid * GLT-1 activator An Effective but Inaccessible Methamphetamine Treatment: Contingency Management (CM) Opportunity Challenges • CM is a behavioral treatment in • Treatment programs receiving which behavioral change targets federal funds are allowed to (such as drug abstinence) are set award a maximum of and carefully monitored, and $75/patient/year rewards are issued for • More is disallowed by HHS compliance under anti-kickback statute • Meta-analyses indicate that CM • Legal concerns have is the most effective behavioral disincentivized uptake of CM treatment for stimulant • Effective CM protocols provide addiction more than $75 • range ~ $200-$2000 NIDA-Supported COVID Policy Research •How does telehealth access affect OUD treatment, including in rural settings? •What is the impact of methadone take home dose policy on treatment retention/adherence and drug use? •How has the pandemic affected syringe service programs, including naloxone distribution and medication enrollment? •Effects of state marijuana laws and COVID-related stress on marijuana use? •How have COVID-related substance use policy changes been disseminated, adopted, and implemented within Tribal communities? HEALing Communities Study Justice Community Opioid Innovation Network 18 States + PR 88 communities >25,000 justice- involved persons • Has the rate of overdoses changed? • Compiled >120 guidelines/resources for justice • Impact on treatment initiation and retention systems responding to COVID-19 • Impact on drug access in the community • Advisory group to provide real-time information • Challenges to providers and first responders to NIDA on COVID-19 impact in justice settings • Challenges to those with SUD 16 Structural Challenges for SUD During COVID-19 • Stress • Stigma • Access to medications for OUD • Limited access to peer-support groups or other sources of social Buffalo NY Methadone Clinic connection March 2020 • Social distancing increases likelihood of opioid overdoses happening with no observers who can administer naloxone .
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