2018 Demystifying Medicine: The opioid epidemic: how, where, and what can be done?

>> WE ALWAYS COMMENT ON THE BROOKLYN BRIDGE FOR TWO REASONS. ONE, MY GRANDFATHER TOOK THE PICTURE AND IT’S A WONDERFUL LOGO FOR WHAT THIS COURSE IS ABOUT. LINKING UP THE ADVANCES IN ENGINEERING AND BIOLOGICAL SCIENCES AND MEDICINE, ON THE OTHER HAND AND WE’RE LIKE THE FELL FELLOS FELLOWS ON THE CATWALK. THE ABSENCE OF THIS KIND OF A BRIDGE, I THINK, CONSTITUTES ONE OF THE BIG PROBLEMS WE HAVE IN MEDICINE, SCIENCE AND WE DON’T ALWAYS SPEAK A LANGUAGE ANYONE CAN UNDERSTAND OR WE CAN UNDERSTAND WITHIN DIFFERENCES. THERE’S THERE’S AN ADDITIONAL ASPECT. IT’S NOT ONLY A MATTER OF RESEARCH AND SCIENCE BUT MEDICINE AND PATIENTS. >> THERE’S A POWERFUL INFLUENCE OF SOCIETY AND POLITICS AND OF PLANNING AHEAD RATHER THAN BEING REACTIVE. IT’S CALLED AN EPIDEMIC BECAUSE MANY PEOPLE ARE INVOLVED BUT AN EPIDEMIC TO WHICH WE REACT TO AN OCCURRENCE BUT WE DON’T SEEM TO BE GOOD IN THE ANTICIPATING EPIDEMIC OF THIS TYPE AND ESTABLISHING OTHER POLICIES THAT PREVENT IT FROM OCCURRING IN THE FIRST PLACE. MANY PEOPLE HAVE ASKED WHAT IS INE — AN OPIOID. IT’S A CLASS OF DRUGS THAT INCLUDE MANY COMPONENTS. THERE ARE ILLEGAL DRUGS LIKE HEROIN AND SYNTHETIC DRUGS LIKE FENTANYL AND LEGAL PAIN RECEIVERS SUCH AS OXYCODONE AND HYPERCODONE AND MORPHINE OR ANY OTHERS. IS IT’S A CLASS OF DRUGS. AND THERE’S MANY CALLED CHINA LIGHT AND TNT AND THIS IS FENTANYL. I THINK IT’S THE MOST EFFECTIVE PAIN RELIEF MEDICATION THAT’S EVER BEEN CREATED. IT WAS SYNTHESIZED BY A CHEMIST WHO FORMED A PHARMACEUTICAL AND IT WAS GIVEN INITIALLY FOR ATHES THESIA AND APPROVED BY THE FDA. IT’S INTERESTING TO READ SOME OF THAT BECAUSE THERE’S STATEMENTS THAT INDICATE IT SHOULD NOT BE VERY ADDICTIVE AND IT APPEARED IN DIFFERENT FORMS AS IN PATCHES FOR RELIEF. IT TURNED OUT TO BE ONE OF THE MOST ADDICTIVE SUBSTANCES KNOWN. NOW MOST COMES FROM THE UNITED STATES BUT FROM CHINA SMUGGLED IN FROM MEXICO AND CANADA AND IT’S OFTEN MIXED WITH OTHER DRUGS FOR ADDED EFFECTS. AND THE PROPERTIES ARE SUBSTANTIAL. SO FENTANYL AND THE OTHER DRUGS ARE PART OF THIS EPIDEMIC WHICH HAS SHOWN TO HAVE ENORMOUS LETHALITY AND FINALLY HAS AWAKENED THE ALMOSTS OF THE BRIDGE, I ALLUDED TO, TO SOLVE SOME OF THE BIG QUESTIONS. HOW DIT START, WITH WHAT DOES IT CONSISTENT OF AND THE UNDERLYING SCIENCE AND CAN IT BE CONTROLLED AND WHAT CAN WE DO ABOUT IT. WE’RE EXTREMELY FORTUNATE TO HAVE TWO LEADERS IN THE GLOBAL DISCUSSION OUR SPEAKERS TODAY. THE FIRST SPEAKER — WHO, I REMEMBER AS IF IT WAS YESTERDAY, IN MAY, 2003 BECAME THE DIRECTOR OF THE NATIONAL INSTITUTE OF DRUG ABUSE. THAT INSTITUTE SUPPORTS MOST OF THE WORLD’S RESEARCH ON ABUSE AND PREVENTION. SHE IS BEST KNOWN FOR HER IMPORTANT ROLE IN ESTABLISHING THE DRUG INSTITUTIABUSE ABUSE
INSTITUTE. SHE LOOKED AT THE EFFECTS OF DRUGS USED FOR ABUSE AND SIMILAR WORK IN THE NEUROBIOLOGY OF OBESITY. SHE GRADUATED FROM THE MEDICAL UNIVERSITY OF MEXICO AND WAS TRAINED IN PSYCHIATRY AND TRAINED IN UNIVERSITY AND SPENT MOST OF HER PROVINCIAL CAREER IN THE BROOK HAVEN NATIONAL LABORATORY IN NEW YORK WHERE HER MAJOR RESEARCH WAS DONE. AND CHAIRMAN OF THE MEDICAL DEPARTMENT AND A PROFESSOR IN PSYCHIATRY AND AT NYU AND A PROFESSOR AT THE MEDICAL SCHOOL IN STONY BROOK AND HAS RECEIVED AWARDS OF ALL DIFFERENT KINDS. SHE WAS ELECTED TO THE MEMBERSHIP IN THE INSTITUTE OF MEDICINE. HAS BEEN HONORED IN OTHER PLISES — PLACES AROUND THE WORLD. IT’S NOT VERY OFTEN I’VE HAD THE OCCASION TO INTRODUCE SOMEBODY WHO IS ONE OF THE TOP 100 PEOPLE TO SHAPE THE WORLD. ONE OF 20 PEOPLE TO WATCH THE MOST POWERFUL WOMEN IN 2017 AND AWARDS AND SURE IS KNOWN TO ALL OF YOU. SHE WILL SPEAK FIRST. OUR SECOND SPEAKER IS THE DIRECTOR OF NINDS, THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE. HE CAME TO NINDS AS A DEPUTY DIRECTOR IN 2007 AND BEFORE THAT WAS PROFESSOR OF NEUROLOGY AT HARVARD, VICE CHAIR OF NEUROLOGY AT THE MASSACHUSETTS GENERAL HOSPITAL. HE GRADUATE THE PERFECT THE — FROM THE UNIVERSITY OF CHICAGO MEDICAL SCHOOL AND TRAINED IN NEUROLOGY AND HIS RESEARCH HAS BEEN IN BASIC NEUROBIOLOGY AND CLINICAL TRIALS. HE HAS BEEN VERY ACTIVE IN ADDRESSING THE ISSUES INVOLVED IN THE SUBJECT WE’RE HERE ABOUT TODAY THE OPIOID CRISIS. >> IT’S A PLEASURE TO SPEAK WITH YOU ALL TODAY AND MY COLLEAGUE AND IT’S INTERESTING YOU HAVE A BRIDGE AND THAT CAN LEAD TO PLACES WE WOULDN’T GO BEFORE AND EXPAND OUR HORIZONS BUT THERE’S pBRIDGES BUT PAIN WAS THE BRIDGE TO THE OPIOID CRISIS WE’RE AT. I WANT TO USE THAT ANALOGY BECAUSE IT IS VERY DIFFERENT FROM ANYTHING ELSE WE’VE SEEN IN THE ADDICTION WORLD. WE HAVE CREATE THE WORST EPIDEMIC EVER AND THE CREATION STEPS FROM THE HEALTH CARE SYSTEM. AND IT’S COME FROM THE NEED OF PATIENTS SUFFERING FROM PAIN TO GET RELIEF FROM THEIR AILMENTS AND THE OTHER COMPONENT IS THE OPIOIDS ARE FANTASTIC DRUGS FOR TREATING ACUTE SEVERE PAIN AND THERE’S NOT MANY OTHERS OUT THERE. THESE TWO COMPONENT THE ACCESS TO MEDICATION THAT’S EFFECTIVE FOR PAIN IS ULTIMATELY WHAT LED THE HEALTH CARE SYSTEM TO BE OV OVER RELIANT AND CONTRIBUTE TO THE ADDICTION AND ABUSE. BUT IT’S BECOME MORE COMPLEX THAN THAT. I WANT TO START BY — I DON’T GET MANY OPPORTUNITIES SO I’LL TAKE THIS OPPORTUNITY TO HIGHLIGHT THE WORK IN TERMS OF THE ADDITION IS A DISEASE OF THE BRAIN. IT’S POSSIBLE AND I HAVE FOUR HERE AND IT’S A PLEASURE TO COME HERE. SO WHAT IS IT WE KNOW AND WHERE WE ARE? THIS ILLUSTRATES IT. YOU CAN SEE THE NUMBER OF FATALITIES PER HUNDRED THOUSAND INDIVIDUALS IN THE UNITED STATES. YOU HAVE THE HIGHEST MORTALITY RATES IN RED. IN 1999 THERE WERE TWO EPICENTERS ONE NEW MEXICO AND THE OTHER IN THE APPALACHIAN REGION. ADVANCE IT 17 YEARS AND YOU CAN SEE CREEPING THROUGHOUT THE UNITED STATES THE AREA THAT STILL HOLDS THE HIGHEST NUMBER OF FATALITIES IS THE APPALACHIANS AND NOW IT’S VIRGINIA AND KENTUCKY, OHIO, TENNESSEE AND NEW MEXICO AND YOU SEE THE NORTHERN EASTERN PART OF THE UNITED STATES AND FLORIDA. IT’S ENTERING INTO ALASKA AND SOME AREAS ARE MORE AFFECTED THAN OTHERS. THE GEOGRAPHIC DISTRIBUTION REFLECTS THE EPIDEMIC AND ITS ORIGINS. THEORIGINS RELATE, OF COURSE, TO OPIOIDS OPPOSED TO OTHER DRUGS LIKE AMPHETAMINE AND COCAINE AND THERE’S DRUGS THAT DESERVE THEIR RESPECTS THIS ACTIVATE THE RECEPTORS AWARDS THE REWARD PART OF THE BRAIN. AND THEY ARE LOCATED IN THE NETWORK RESPONSIBLE FOR PROCESSING AND PERCEIVING PAIN AND THAT INCLUDES CORTICAL AREAS THAT LOOKS AT THE PAIN AND IT ALLOWS FOR FILTERING OF PAIN AND THERE’S ANOTHER REGION DOWN THERE THAT IS NOT MARKED WHICH IS THE AMYGDALA RESPONSIBLE FOR EMOTIONS AND GIVES THE EMOTIONAL COMPONENT OF PAIN. AND THE OPIOIDS PLAY MULTIPLE ROLES. VERY IMPORTANT IN REGULATING PAIN AND PLEASURABLE RESPONSES. THOSE ARE FUNDAMENTALLY THE WAY THE BRAIN IS WIRED TO MOTE VIT OUR — POET — MOTIVATE SOMEONE. WHEN A MOTHER HOLDS AN INFANT IT’S REWARD BAG BECAUSE OF THE SYSTEM AND WHAT’S REMARKABLE IS WHEN SOMEONE IS IN A LOT OF PAIN AND THEY’LL BE EXPOSED TO A PAINFUL PROCEDURE TO TOUCH THEM AND IT’S THINGS WE DON’T NECESSARILY THINK BUT IS IMPORTANT. IT’S A SYSTEM THE OPIOIDS THAT REGULATE THESE IMPORTANT PROCESSES THAT RELATES TO ATTACHMENT THAT RELATES TO REWARD AND THINGS LIKE FOOD THAT ALLOWS US TO BE MOTIVATE AND CAN ALSO LEAD US TO ADDICTION. LIKE OPIOIDS, ALL THE OTHER DRUGS ARE ACTIVATING THE AREA AND BY DOING THAT, THEY RELEASE DO DOPAMINE LEAD TO OTHER SYSTEMS IN THE BRAIN THAT THEN MAKES YOU VULNERABLE TO IMPULSIVE AND COMPULSIVE BEHAVIORS. SOME ARE RELATE TO A COMMON EFFECT OF THE DRUG AND WE AND OTHERS HAVE SHOWN THE REPEATED STRAEGS OF ADMINISTRATION OF THE DRUGS ADMINISTRATION RELEASES THE RECEPTORS IN THE HUMAN BRAIN. SO DOPAMINE WHICH IS A NEUROTRANSMITTER WHICH IS INVOLVED WITH REWARD AND TAKE THE INFORMATION FROM RECEIVES SIGNALLED THROUGH THE ENDOGENOUS C CANALS AND TRANSLATES IT INTO A SIGNAL AND IT’S AT THE ESSENCE OF MOTIVATION AND THE DOPAMINE RECEPTOR SYSTEM ENABLES US TO REGULATE THE ACTIONS AND IT’S ONE OF THE MAIN SIGNALLING MECHANISMS RELATED TO THE RECEPTOR SYSTEM. WHETHER IT’S PAIN OR DOPAMINE OR HEROIN, YOU’RE INTERFERING WITH SELF-REGULATION AND CONTROL AND THIS IS COMMON IN ADDICTION. WE KNOW THE DRUGS WHICH CAN BE VERY HIGHLY EFFECTIVE AND HAVE THE EFFECT OF PRODUCING ADDICTION. WHAT WAS THE PROBLEM? WE HAVE HAD A PROBLEM OF HEROIN AND IT’S BEEN VERY LOW PREVALENCE AND HEROIN HAS TESTED FOR 20 YEARS UNTIL THE EPIDEMIC AND ONE WOULD SAY 300,000, 400,000 INDIVIDUALS. IT WAS STABLE. AND IT WAS THE PRESCRIPTION OF OPIOIDS THAT STARTED TO UNBALANCE THAT AND LOOK AT HOW RAPIDLY PRESCRIPTIONS WENT. I’M IDENTIFYING TWO CLASSES. THE ONES MOST FREQUENTLY PRESCRIBED, OXYCODONE AND YOU CAN SEE AS OF 2011 THERE WERE 219 MILLION PRESCRIPTIONS IN THAT YEAR PRESCRIBED IN THE UNITED STATES WHICH BASICALLY IMPLIED MOST MALES WOULD BE ABLE TO SUPPLY THEMSELVES FOR A MONTH AND CLEARLY WE’RE NOT AT THAT NEED AND THEY WERE NOT UTILIZED BUT IT LED TO A MARKET AND PEOPLE START TO SEEK THESE AS THE FAVORED DRUG OF ABUSE. AND THEY BELIEVED BECAUSE THEY WERE MEDICATION THEY WERE SAFER AND THAT’S WHERE EVERYTHING COLLAPSE. AND WE NOW RECOGNIZE THE PRESCRIPTIONS ISSUED IN THE UNITED STATES HAS TRIGGERED THE CRISIS. THERE’S BEEN AN AGGRESSIVE CAMPAIGN TO MINIMIZE THE PRESCRIPTIONS GIVEN TO PATIENTS AND WE HAVE STARTED TO SEE A DECREASE IN THE EQUIVALENCE PROVIDED TO PATIENTS. WE’RE GOING IN THE RIGHT DIRECTION. WE STILL HAVE A MASSIVE OVER PRESCRIPTION PROBLEM IN OUR COUNTRY. I THINK IT DESERVES EMPHASIS. THE FACT WE’RE OVER PRESCRIBING OPIOIDS DOES NOT MEAN WE’RE IMPROVING THE PATIENTS WITH SEVERE CHRONIC PAIN. THERE’S NO ASSOCIATION WITH IT OR DO WE KNOW THERE’S BENEFITS IN GENERAL TO OVER PRESCRIBING. WE KNOW FROM CLINICAL EVIDENCE, SOME PATIENTS FOR WHICH NOTHING ELSE WORKS WITH CHRONIC PAIN. YOU MAY JUSTIFY THE USE OF AN OPIOID MEDICATION BUT IT’S VERY RESTRICTIVE CIRCUMSTANCES THAT THESE MEDICATIONS SHOULD BE GIVEN FOR EVERY DAY MANAGEMENT OF CHRONIC PAIN. I WANT TO EMPHASIZE, IT DOESN’T MEAN THEY DON’T HAVE A VALUE. SEVERE CHRONIC PAIN THAT IS NOT PROPERLY TREATED HAS A VERY NEGATIVE OUTCOME AND HIGH RATES OF SUICIDE. WHAT HAS BEEN VERY FRUSTRATING AS WE’RE WATCHING THE OPIOID EPIDEMIC CLIMBING AND CLAIM MORE PEOPLE WHO ARE DYING IS DESPITE THE FACT WE’VE BEEN ABLE TO DECREASE THE NUMBER FOR OPIOIDS, WE HAVE NOT BEEN ABLE TO BRING DOWN THE NUMBER OF FATALITIES FROM OPIOID. THE OFFICIAL OF FATALITIES HAVE BEEN INCREASED AT THE RATE OF A 22% TO 25% INCREASE PER YEAR. IF YOU LOOK AT WHAT’S GOING ON, YOU HAVE AN UNDERSTANDING OF WHY THAT’S HAPPENING. LOOK AT THE PRESCRIPTION IN THE GREENISH LINE AND IT’S STILL GOING UP. SOME PEOPLE SAY IT’S STABILIZING AND SOME OF THE STATES LIKE CALIFORNIA OR ACTUALLY EVEN IN MASSACHUSETTS, THEY’RE SEEING A DECLINE IN OVERDOSES FOR PRESCRIPTION OPIOIDS. BUT HEROIN HAS STARTED TO INCREASE STARTING IN THE EARLY 2000s. VERY HIGH PURITY AND AS RESULT OF PEOPLE BECOMING ADDICTED AND THE ACCESSIBILITY AND THE LOWER COST OF THE DRUG THEY SHIFT FROM USING PRESCRIPTION OPIOIDS TO HEROIN AND IT’S INCREASING THE OVERDOSE OF FATALITIES AND THEN TO MAKE THINGS WORSE, THE BLOCK LINE IS RECENTLY PERHAPS, 2014, MAYBE 2015 WE’VE SEEN AN INCREASE IN THE NUMBER OF FACE — FATALITIES ASSOCIATED WITH PHEN NA — FENTANYL IT’S 50 TIMES MORE POTENT THAN HEROIN AND WHAT THE POTENCY MEANS IS YOU NEED A SMALL DOSE IN ORDER TO PRODUCE THE SAME EFFECT. WHICH MEANS IF YOU’RE A DRUG DEALER IT’S EASIER TO BRING OVER THE BORDER BECAUSE YOU CAN CARRY IT IN YOUR POCKET IN A LITTLE VIAL THAT CAN DISTRIBUTE OVER THOUSANDS OF DOSES AND WITH SYNTHETIC CHEMISTRY BECOMING MORE ADVANCED WE HAVE NEW DRUGS WITH GREATER POTENCY AND ONE MAIN ENTRANCE OF THEM IS THROUGH THE MAIL. MOST IS COMING FROM MANUFACTURERS IN CHINA. SOME IS STARTING TO COME DIRECTLY FROM CHINA OR INDIRECTLY TO MEXICO AND IT’S THE BLACK LINE RESPONSIBLE FOR THE MORE THAN DOUBLING OF THE EPIDEMIC IN THE YEAR. MASSACHUSETTS HAS SEEN A REDUCTION IN PRESCRIPTIONS BUT HAVE SEEN 80% OF THE BEDS FROM OVERDOSES IN MASSACHUSETTS ARE ATTRIBUTED TO FENTANYL AND THEY TRANSFERRING FROM PRESCRIPTION OPIOIDS TO HEROIN TO FENTANYL. AND WHAT OUR PREVENTION EFFORTS HAVE TO TARGET BOTH OF THESE STREET DRUGS. WE CANNOT ABANDON THE PRESCRIPTION OPIOID BUT WE NEED TO FOCUS ALSO ON THE ADDITIONAL STRATEGIES. THIS IS THE TRIANGLE WE NOW EMBRACE AT THE NIH AND BOTH WALTER AND I HAVE BEEN WORKING TO COME UP WITH SOLUTIONS FOR THE CRISIS. I’D LIKE TO PUT AT THE TIP OF OUR STRATEGY, PAIN MANAGEMENT. IF WE DON’T ADDRESS THE NEED TO ADDRESS PAIN THERE WILL ALWAYS BE A BLACK MARKET FOR DRUGS SINCE THEY CAN BE LIFE SAVING BUT WE NEED TO ADDRESS THE STRATEGIES IN ORDER TO PREVENT AND TREAT PEOPLE THAT BECOME ADDICTED AS WELL AS PREVENT AND TREAT THE OVERDOSES BECAUSE THAT IS THE MAIN DRIVER OF THE FATALITIES. AND WE’LL DISCUSS THE ISSUE OF PAIN AND WHAT OUR STRATEGY AS A WHOLE IS TO COME UP WITH ALTERNATIVE TREATMENTS THAT ARE SAFER AND AS EFFECTIVE AS OPIOID MEDICATIONS AND HOPEFULLY MORE EFFECTIVE FOR MANAGEMENT OF CHRONIC PAIN BECAUSE WITH OPIOIDS WE BECOME RAPIDLY TOLERANT WHICH IS A CHALLENGE BECAUSE YOU NEED HIGHER AND HIGHER DOSES. THE HIGHER DOSE YOU NEED THE GREATER THE RISK OF ADDICTION AND OVERDOSE. THIS IS WHERE THE BEAUTY OF SCIENCE IT. IT SHOWS WE CAN NOW UNDERSTAND HOW IT INTERACTS WITH THE RECEPTOR. IN THE PAST WE ASSUMED THE PATH WAYS AND IN FACT ONE OF OUR GRANTEES IS COMING UP WITH REMARKABLE DATA SHOWING AND PERHAPS ADDRESSING THE QUESTION AND SAYING WE KNOW THE ENDOGENOUS RECEPTOR IS FOR PAIN BUT WHY HAVE WE BECOME TOLERANT SO A NEW PAPER SHOWS THE ENDOGENOUS PEPTIDES BINDING TO THE RECEPTOR ARE SIGNALLING WHEN THEY GET INTERNALIZED INSIDE THE CELL AND THE SIGNALLING PROCESS IS DIFFERENT FROM THAT OF THE CURRENT DRUGS. AGAIN, I’M PROVIDING BY THIS KNOWLEDGE ONE CAN LOOK AT THE MECHANISMS OF TOLERANCE. AND THIS IS A DIFFERENT CONCEPT WHICH IS NOW BEING FOLLOWED UP BY THE PHARMACEUTICAL INDUSTRIES AND THAT WOULD BE DEVOID OF THE EFFECTS OF MOST OPIOID DRUGS THAT TAKES ADVANTAGE INTO ENGAGING THE SYSTEM BUT NOT THE INTRACELLULAR RESTING ONE. WHETHER IT’S SUCCESSFUL OR NOT WE’LL FIND OUT SOON BECAUSE THE COMPOUND IS A CLINICAL TRIAL AND EVALUATED. AND I WANT TO LOOK TO THE TREATMENTS. THERE’S THREE CLASSES. THREE MEDICATIONS. MORE THAN FOR BASICALLY ALL THE OTHER DRUGS OF ABUSE OTHER THAN ALCOHOL AND TICK — NICOTINE AND ONE HAS FULL EFFECTS THEN WE HAVE A PROTAGONIST AND YOU HAVE TO AND YOU HAVE TO [AUDIO DIFFICULTIES] >> AND THEY’VE BEEN SHOWN TO DECREASE OPIOID USE AND DECREASE CRIMINAL ACTIVITY AND TRANSMISSION SUCH AS HIV, HEPATITIS C AND RETAINING TREATMENT AND THEY’RE NOT BEING USED AND IF YOU GO INTO BASICALLY OBSERVE THROUGHOUT THE UNITED STATES, TREATMENT PROGRAMS THAT ARE FOR OPIOID USE DISORDERS LESS THAN ONE-THIRD OFFER ACCESS TO MEDICATION AND IT’S THE STIGMA. THE STIGMA BRAIN. AND IT REACTS TO THE EFFECTS. THE FASTER THE EFFECTS THE MORE THE REWARD AND WHEN YOU INJECT THE DRUG IT’S MORE ADDICTIVE BECAUSE THE SLOWER ROUTE SLOWS THE PHARMACOGENETICS AND IT’S THE CRAVING THAT EMERGES IN THE OPIOID SIGNALLING SYSTEM THAT HAPPENS WHEN THE MORPHINE DISASSOCIATES. SO THERE’S LOTS OF MISUNDERSTANDING OF HOW THE MEDICATION WORKS THAT HAS LED TO PEOPLE NOT UTILIZE IT TO THE EXTENT AND THEY’RE EFFECTIVE AND ONE OF THE BIG STRATEGIES IS HOW DO WE IMPROVE ACCESS TO THE MEDICATIONS. THERE’S ANOTHER CAVEAT WE HAVE TO RECOGNIZE. AS EFFECTIVE AS THEY ARE, THEY STILL HAVE A RATE OF PEOPLE ON TREATMENT. 50% WERE RELAPSING IN SIX MONTHS. YOU THINK THAT’S A BIG RELAPSE RATE BUT IF YOU DON’T TREAT THEM 95% WILL RELAPSE IN ONE WEEK, IF NOT THREE DAYS. THE DIFFERENCES ARE VERY LARGE. AT THE SAME TIME, THAT IS CONSTRAINED. 50% RELAPSE IN SIX MONTHS IS NOT ACCEPTABLE BECAUSE PATIENTS HAVE A HIGH RISK OF OVERDOSE WHEN THEY RELAPSE. HOW DO WE IMPROVE THE NUMBERS TO DECREASE THE RELAPSE RATES? LET’S START WITH THE CAS INDICATED — CASCADE OF OPIOID USE DISORDER AND THERE’S PRESCRIPTION OPIOIDS AND FENTAN FENTANYL. WE HAVE DIAGNOSED TWO OF THIS — TWO-THIRDS AND OF EVERY STEP OF THE WAY YOU SEE THE ENORMOUS AMOUNT OF GAP, THE HUGE GAP THAT EXISTS BETWEEN WHERE WE SHOULD BE AND WHERE WE ARE AND IF WE NEED TO SOLVE THE CRISIS WE HAVE TO REDUCE THAT GAP DRAMATICALLY AND THE OTHER IS YES, WE WANT TO HAVE TREATMENT TO MAKE IT EASIER FOR INDIVIDUALS TO BE COMPLIANT WITH THEIR MEDICATION AND WE’RE FAVORING EXTENDED-RELEASE FORMULATIONS BECAUSE THEY’RE LOW-HANGING GROUP. IF YOU DON’T HAVE TO THINK OF GOING TO A METHADONE CLINIC ON A DAILY BASIS, IF YOU’RE TRYING TO RECOVER AND START WORK, THIS IS EXTREMELY DIFFICULT TO DO. HOW CAN WE MAKE IT AN EASY FORMULATION. THERE ARE OTHER STRATEGIES FROM DRUG COMBINATIONS TO NEW TARGETS TO VACCINES TO OTHER TREATMENTS. AND THERE’S AN EXAMPLE OF HOW SUCCESSFUL IT CAN BE IS THE FORMULATION FOR THE DRUG AND IT GOES BY THE TERM OF VIVITROL AS A TREATMENT FOR THE DISORDER. AND YOU HAVE OPIOIDS IN PLACEBO AND IN VIVITROL THERE WERE CLOSE TO 90% WHO WERE ABLE TO BE COMPLETELY ABSTINENT DURING THE PERIOD OF THE TRIAL CLOSE TO SIX MONTHS. RECENTLY, WE’VE PARTNERED WITH RAYBURN TO DEVELOP A SIX-MONTH IMPLANT TO MAKE IT EASIER FOR THEM TO BE COMPLAINT WITH THE MEDICATION AND THIS WAS APPROVED IN MAY 26, 2016. IT CAN ONLY DELIVER EIGHT MILLIGRAMS AND MOST PATIENTS REQUIRE 16 AND 20 MILLIGRAMS SO IT CAN ONLY BE USED IN WHAT IS ESTIMATED TO BE 20% TO 30% OF PATIENTS THAT CAN TOLERATE SUCH A LOW DOSE. AND THIS IS DATA FOR VIVITROL TO COMPARE TREATMENT VERSUS THE ROW LAPSED TREATMENT AND YOU CAN SEE THE DIFFERENCES IN THE MEDICATION AND YOU LOOK AT HOW EFFECTIVE THEY WERE. AND THIS IS SOME OF OUR BEST MEDICAL CENTERS IN THE UNITED STATES LINKED TO THE CRIMINAL JUSTICE SYSTEM AND THIS IS NOT BASED ON HIGH RATE OF MORTALITY. THERE WERE NONE TREATED WITH VIVITROL. HIGHLIGHTING THE IMPORTANCE OF EXPANDING ACCESS TO THESE MEDICATIONS AS A WAY TO PREVENT FATALITIES. IN THE MEANTIME, WE ARE ALSO AWARE AS A RESULT OF RESEARCH WE HAVE COME TO UNDERSTAND THE CHANGES IN THE BRAIN THAT OCCUR WITH ADDITION AND HAVE BEEN ABLE HOW THEY RELATE TO THE CONTROL D AND WHETHER IT’S ALCOHOLISM AND WE NOW LOOK AT IT AS HTARGETING AS MOLECULAR TARGETS OR STIMULATION TECHNOLOGIES SUCH AS MAGNETIC STIMULATION AS A MEAN TO MODULATE THE SEQUENCE. THAT’S RESEARCH THAT IS ONGOING. AND AN AREA WE’VE DONE RESEARCH AS IT RELATES TO LOOK AT VACCINES OR PASSIVE IMMUNIZATION AGAINST DRUGS. THE IDEA IS LIKE WITH ANY OTHER DRUG. YOU VACCINE AGAINST HEROIN OR FENTANYL AND YOUR BODY PRODUCES ANTIBODIES THAT ARE CIRCULATING IF THE DRUG SO WHEN YOU TAKE THE DRUG AND IT’S IN YOUR BLOOD, THE ANTIBODIES BIND TO THE DRUG AND THIS INTERFERES WITH THE PASSAGE TO THE BLOOD BRAIN BARRIER AND THE DRUG IS SEQUESTERED AND CANNOT LEAVE THE BLOOD. IT WORKS WELL. WE CAN PREVENT THEM FROM TAKING DRUGS AND FROM DYING FROM FENTANYL OVERDOSES IN MICE. THE BIG CHALLENGE IS TO TRANSLATE THIS TO HUMANS WHICH WERE LOOKING AT THE VACCINES WHICH HAVE NOT BEEN STRONG ENOUGH TO PREVENT THE DRUG FROM ENTERING THE BRAIN IN SUFFICIENTLY HIGH QUANTS. AND NOW THE PASSIVE IMMUNIZATION CAN GENERATE HIGHER ANTIBODIES IS ANOTHER STRATEGY THAT IS LIKELY TO BE EASIER TO APPLY. RESEARCHERS ARE WORKING AT IT AND ANTIBODIES HAVE BEEN FORMED TO TACKLE HEROIN AND FENTANYL ANIMALS.VENTS FATALITIES IN – THAT IS FROM THE MEDICATION DEVELOPMENT. FROM THE PERSPECTIVE IN THE NEEDS OF PATIENTS TO GIVE THEM ACCESS TO MEDICATION. IF YOU LOOK AT THE NUMBER OF SPECIALIZED TREATMENT CENTERS IN OUR COUNTRY YOU’LL FIND OUT THEY’RE NOT SUFFICIENT TO TAKE CARE OF PATIENTS AND THOSE IN THE HEALTH CARE SYSTEM RECOGNIZE THAT BECAUSE PATIENTS ARE COMING TO THE HOSPITAL AND THERE’S NOT SUFFICIENT TREATMENT PROGRAMS. THE HEALTH CARE SYSTEM AND THE HEALTH CARE SYSTEM ITSELF HAS START TO COME UP TO ADDRESS THE NEED OF PATIENTS SUFFERING FROM AN OPIOID USE DISORDER AND WE HAVE DEVELOPED NEW MODELS OF CARE THAT TAKE ADVANTAGE OF SYSTEMS WHERE PATIENTS CAN BE TREATED. WE FOCUS SPECIFICALLY IN TWO SYSTEMS THAT INCREASE ALL OVER THE UNITED STATES. THE HEALTH CARE SYSTEM AND THE CRIMINAL JUSTICE SYSTEM AS ONE THAT WE CAN ENROLL IN TO GETTING ACTIVE IN THE SCREENING OF INDIVIDUALS WITH OPIOID USE DISORDER. THIS IS AN ILLUSTRATION OF TWO APPROACHES THAT ARE BEING DONE. AGAIN, THE IMPLEMENTATION STRATEGIES FOR DELIVERING IN THIS CASE, DIFFERENT DRUGS AND YOU CAN SEE EMERGENCY ROOM ADMISSIONS AS A FUNCTION OF THE ENROLLMENT FROM PHYSICIANS WORKING IN CLOSE COLLABORATION WITH NURSES. THIS IS IMPORTANT BECAUSE IT’S A MODEL THAT SUS STAINS US. AS WE RECOGNIZE HOW MANY PEOPLE REQUIRE TREATMENT WE HAVE TO LOOK AT BROAD ACCESS TO PATIENTS SUSTAINS THE ABILITY. AND YOU CAN SEE IN SIX MONTHS IN PURPLE AND AT 12 MONTHS AND 12 MONTHS VERSUS THE EMERGENCY ROOM ADMISSIONS BEFORE THE OPE NEF RIN — THE DRUG HAS BEEN IMPLEMENTED IN THE STATES OF MASSACHUSETTS WHICH HAS BEEN ONE OF THE MOST ACTIVE IN ENROLLING THE AGENCY IF THE TREATMENT OF OPIOID USE DISORDER. ON THE RIGHT IS ANOTHER STRATEGY FOR THE SYSTEM. THEY DID A PILOT STUDY TO INVOLVING THE PHYSICIANS ON PRESCRIBING IT WHEN THE PATIENTS ENDED UP IN THE EMERGENCY DEPARTMENT. WHAT THEY SHOW IS WHEN THEY DID THAT, THAT SIMPLE INTERVENTION OF INITIATING THE DRUG IN THE EMERGENCY DEPARTMENT OPPOSED TO A BRIEF INTERVENTION THEY DECREASED THE USE AND INCREASED THE TREATMENT AND PATIENT FACILITIES. NOW WE’RE DOING A MULTIPLE CLINICAL TRIAL INVOLVING SITES IN THE UNITED STATES TO IMPLEMENT THE ADMINISTRATION TO PATIENTS WHERE IT’S A UNIQUE OPPORTUNITY TO BE ABLE TO ENGAGE THEM TO TREATMENT. WE’RE SEEING MORE AND MORE PEOPLE BEING REVERTED FROM AN OVERDOSE IN RESPONSE TO NALOXONE AND REPEATED OVERDOSES, IN MANY INSTANCES, 10, 20, 30 IN A YEAR AND WHEN A PATIENT OVERDOSES THE LIKELIHOOD OF A REOCCURRENCE IS HIGH. IF YOU END UP IN AN EMERGENCY ROOM WITH AN OVERDOSE OF OPIOID WHAT IS THE LIKELIHOOD OF SOMEONE DYING AND 10% OF PATIENTS WILL BE DEAD WITHIN A YEAR. THESE ARE PATIENTS THAT ARE NOT PROTECTED FROM DYING AND THEY ARE CREATING MODES OF CARE WHETHER YOU CREATE THE BREACH THAT WILL BRING THEM INTO THE TREATMENT. IT SEEMS TO BE SOMETHING THAT COULD DECREASE THE HIGH MORTALITY ASSOCIATED WITH THE EPISODES. SOME INDIVIDUALS ARE AT HIGHER RISK OF THE DRUG. AND WHETHER ONE STARTS WITH THE CRIMINALIZATION OF DRUG ADDICTION WHICH WE DON’T SUPPORT. IF YOU’RE GOING TO PUT THEM IN JAIL, WHAT IS CLEAR IS YOU SHOULD TREAT THEM. OU IMPACTFUL THAT IS, THIS IS A STORY FROM ENGLAND IN WHICH THEY AGGRESSIVELY INITIATED TREATMENT SYSTEM AND WHEN THEY DO THAT, – THEY’LL BE TREATED WITH THE REDUCTION IN MORTALITY IN THE FIRST YEAR WHERE THEY DID SOMETHING SIMILAR THEY INITIATED THE TREATMENT THROUGHOUT THE PRISON SYSTEM IN RHODE ISLAND AND WHAT THEY SHOWED WAS THAT IMPLEMENTATION PRODUCED A SIGNIFICANT RELEASE DECREASING TE NUMBER OF OVERDOSE DEATHS. AT THE POPULATION LEVEL, 12.5% DECREASED AND THE REST OF THE COUNTRY IS INCREASING AND IF YOU LOOK AT THE INCREASE IN MORTALITY OF THOSE WHO LEFT THE PRISON SYSTEM, THEY DECREASED IT BY 50% COMPARED TO 2016. HIGHLIGHTS THE UNIQUE OPPORTUNITY WE HAVE TO ENSURE THERE IS TREATMENT IN THOSE WHO HAVE AN OPIOID USE DISORDER IN JAIL AND CREATE A PROGRAM SO WHEN THEY LEAVE THEY’RE LINKED WITH A HEALTH CARE SYSTEM AND WE’RE PROMOTING RESEARCH. THE LAST SERIES OF SLIDES COME FROM ANOTHER ASPECT WE DON’T DWELL MUCH ON. HAVE YOU DATA FROM 2016 FOR DRUG POISONING DEATHS. IT ILLUSTRATES THIS IS INCREASED IN POPULATIONS OF POVERTY AND IT’S DECREASED IN A LIFE TIME EXPECTANCY OF AMERICANS LIVING NOW OPPOSED TO OTHER AREAS OF THE WORLD WHERE BASICALLY LIFE EXPECTANCY AND THOSE WHO HAVE SIMILAR OR LOWER ECONOMIC BACKGROUNDS IS INCREASING AND THERE’S SIGNIFICANT DECREASES IN SUICIDE AND TREATMENT. THESE ARE DISEASES OF DESPAIR. IT’S IMPORTANT TO THINK ABOUT. AS WE DISCUSSED IN HOW WE PREVENT OVERDOSES, WE HAVE TO KEEP OUR EYES ON THE INDIVIDUALS THAT ARE BORN OUT OF CONDITIONS WHERE HOPELESSNESS AND VULNERABLELESS MAKE THEM MORE PRONE TO TAKING DRUGS AND I CANNOT THINK OF ANY OTHER IMAGE THAT CAN PORTRAY THE SENSE OF DISTRESS AND DESPAIR THIS HAS GENERATED IN THE COUNTRY. THANK YOU VERY MUCH. >> THANK YOU. THAT WAS GREAT. YOU SHOWED A CORRELATION BETWEEN THE OVERDOSE ASSOCIATED DEATHS AND THE INCOME OF THE PEOPLE AND HOW IT WORK WITH THE INCOME OF THE AREA. IS IT PEOPLE ARE DYING BECAUSE THEY’RE NOT RECEIVING PROPERTY TREATMENT? >> THIS IS AN EPIDEMIC. WE’RE GETTING PEOPLE THAT ARE BECOMING ADDICTED AND DYING AND THEY’RE GETTING MEDICATIONS AND THEN THEY OVERDOSE. WE’RE SEEING MORE WHITE WOMEN DYING BECAUSE THEY HAVE MORE ACCESS TO TREATMENT AND THEY HAVE ACCESS TO OPIOIDS. WE’RE SEEING IN AREAS LIKE APPALACHIA THERE’S NOT MANY ALTERNATIVES. PEOPLE DON’T HAVE A GOOD EDUCATION. AND GIVE THEM OPPORTUNITIES TO LOOK FORWARD. IF YOU DON’T HAVE ANY THE LIKELIHOOD YOU WOULDN’T ENGAGE ON THIS TYPE IS HIGHER. THE GREATER STRESSORS YOU HAVE IN YOUR LIFE THE LESS YOU HAVE THE OPPORTUNITIES FOR DEVELOPING YOURSELF. THEN THERE’S AN OPPORTUNITY FOR EXPLORATION WHERE A YOUNG PERSON AND YOU SEE THE ABILITY OF MALES ENGAGING IN RISKY BEHAVIOR IN CERTAIN STAGES OF THEIR LIFE AND THERE’S RANDOMNESS AND FRIENDS SAY YOU HAVE TO TRY THIS DRUG AND THEY TRANSITION. WHAT I JUST WANTED TO SHOW IS WE TEND TO FORGET THAT COMPONENT OR THE SOCIAL ASPECT OF ADDICTION. AND HOW IMPORTANT IT IS FOR US TO PREVENT PEOPLE FROM BECOMING ADDICTED. WE ALSO HAVE TO RECOGNIZE WE HAVE TO DO PREVENTION FROM PEOPLE EXPERIMENTING FROM DRUGS AND STARTING TO GET INVOLVED WITH DRUGS SUCH AS FENTANYL. IT’S BOTH SIDES. THIS IS THE ONE THAT’S FORGOTTEN. [INDISCERNIBLE] >> IN OPIOID WITHDRAWING WE UNDERSTAND THE INTRACELLULAR MECHANISMS ARE COMPLETELY DISRUPTED. THAT’S ONE OF THE MECHANISMS ASSOCIATED WITH THE WITHDRAWAL AT THE CELLULAR LEVEL. WE ALSO — THERE IS ALSO ADAPTATION AT THE NEUROCIRCUITRY LEVEL THAT CREATE A STRESS RESPONSE WITH THE HYPOTHALAMUS AND AMYGDALA AND THE OTHER ENDOGENOUS SYSTEM INVOLVED IN THE NEGATIVE ASPECTS IS THE RECEPTORS. I SPOKE ABOUT THE RECEPTOR AND THAT IS IS AN AVERSE SIGNALLING COMPONENT. WHERE THE OPIOID SYSTEM IS REWARDING. THE SYSTEM IS RESERVIVE. IT CAN CREATE A DYSPHORIA WHEN SOMEONE IS IN WITHDRAWAL. >> WHY [QUESTION INAUDIBLE] >> WE HOPE TO UNDERSTAND THE MEC NICHES THAT LEAD TO THIS AND ALLOW US TO ACCELERATE THE MEDICATIONS FOR PAIN AND OPIOID USE DISORDER. THAT’S OUTSIDE OF OUR CONTROL RIGHT NOW. THIS HAS BECOME ONE OF THE PIRATES OF THE NIH AND BRING TOGETHER THE DIFFERENT AGENCIES BECAUSE IT WON’T BE SOLVED BY ONE AGENCY. >> YOU MENTION THE LAP RATE IS HIGH. DO WE UNDERSTAND WHAT WE KNOW ABOUT THE DRUG RESISTANCE IN A WAY ON THIS SITUATION. YOU HAVE SOMEONE ON ANTIDEPRESSANT AND DOING WELL AND THEN RELAPSE. THE RELAPSE RATE CAN BE CLEARLY ASSOCIATED WITH ANOTHER STRESSOR. A LOVED PERSON DIES AND THE STRESSOR CAN LEAD YOU TO RELAPSE. AND I THINK IT DOES MAKE SENSE THERE MAY BE A TOLERANCE MECHANISM. THERE’S NOWHERE TO ANSWER THAT QUESTION. >> IS THERE A LINK BETWEEN THE LEGALIZATION AND MARIJUANA AND THE OVER OUTILIZE UTILIZATION OF
THE STREET DRUGS IN COMBINATION WITH FENTANYL. THE INTERACTION WE LIKE TO SAY THERE ARE TWO PAPERS THAT LOOK AT THE DATA ON MEDICAID AND MEDICARE IN WHICH THEY SHOW INDIVIDUALS THAT CAME FROM STATES WHERE THEY HAD LEGALIZED MEDICAL MARIJUANA REDUCED THE NUMBER OF OPIOID PRESCRIPTIONS AND THE THOUGHT WAS YOU SHOULD MAKE MARIJUANA MEDICALLY LEGAL. I DO NOT NEGATE THAT IN SOME PATIENTS THIS MAY BE THE CASE. I THINK IT NEEDS TO BE TESTED AND THERE’S DATA THAT SHOWS THOSE INDIVIDUALS THAT WERE SMOKING MARIJUANA THEY WERE MORE LIKELY ONE OR TWO YEARS LATER TO BE ADDICTED TO OPIOIDS. IT WAS A PRIMING EFFECT TO MAKE YOU MORE VULNERABLE TO THE ADDICTIVENESS. YOU CAN HAVE A POPULATION THAT IS BASICALLY EXPERIMENTING ON USING IT RECREATIONALLY INCREASING THE LIKELIHOOD OF ADDICTION AND INCREASES THE LIKELIHOOD OF AN OPIATE. WE NEED TO DO BETTER RESEARCH TO UNDERSTAND HOW THE CHANGES IN POLICIES ARE EFFECTING PATIENTS ON ADDICTION AND AT THIS TIME, A LOT OF THE INFORMATION IS ANECDOTAL OR LOOKING AT DATABASES SPEAKING AT THE MULTIPLE LEVELS. >> YOU SHOWED THE EXPRESSION PATTERNS IN HEALTHY INDIVIDUALS EARLY ON IN THE DOPAMINE RECEPTORS. DID THESE EXPRESSION PATTERNS EVER RETURN TO NORMAL AFTER THE PEOPLE PRESUMABLY MAKE A RECOVERY. >> WE SEE SOME PATIENTS RECOVER AND IN ANIMAL EXPERIMENTS THEY’VE SEEN THE RELATION OF THE DOPAMINE RECEPTORS ARE STILL PRESENT. IN RODENTS THERE’S A VIABILITY. WE KNOW IN A STRESSFUL ENVIRONMENT IT CAN IMPACT THE RECEPTORS. IT’S NOT JUST THE ONE TO ONE EFFECT. I’M GIVING THE MICROPHONE TO WALTER. pI’M SORRY.STIONS. THE DOCTOR WILL BE HERE AT THE END OF THE SECOND TALK. PLEASE SAVE SOME QUESTION. >> FORTUNATELY, I’LL HAVE TO BE QUICK. I HAVE TO GO TO THE AIRPORT. I JUST WANT TO SAY THE PROBLEM WE’RE IN NOW HAS BEEN REPEATED SINCE 3400 B.C. OPIUM WAS CULTIVATE AND HIPPOCRATES WROTE ABOUT IT AND WAS A PROBLEM ESPECIALLY FOR WOMEN, WHICH WE’LL TALK ABOUT AND IT SPREAD IN THE WORLD AND IN PERIODS OF EUROPE IT DISAPPEARED AND CONSIDERED TO BE AN EVIL TYPE OF AGENT. THEN IN THE 1500s THE DUTCH WERE ABLE TO GET THE CHINESE HOOKED ON SMOKING OPIUM. THEY BROUGHT OPIUM INTO CHINA AND ADDICT THE COUNTRY. THE CHINESE COUNTRY TRIED TO STOP THIS AND THE BRITISH DEFEAT THE CHINESE WHO WERE TRYING TO PREVENT THEM FROM SELLING OPIUM. THE BUSINESS OF CREATING ADDICTED POPULATIONS AND PEOPLE MAKING MONEY HAS BEEN IN HISTORY. IN THE U.S., OPIUM HAS BEEN THROUGHOUT OUR HISTORY. IT WAS USED FOR PAIN AND IN REVOLUTION WARTIME THERE WAS A BIG PROBLEM AFTER THE CIVIL WAR. IT WAS ESTIMATED 10 MILLION OPIUM PILLS WERE HANDED OUT TO THE WAR SOLDIERS. THE INTRAVENOUS SYRINGE WAS INTRODUCED AND START THE INTRAVENOUS INTRODUCTION OF MORPHINE AND CHEMISTS WERE ABLE TO PURIFY HEROIN AND IT WAS USED TO GET PEOPLE OFF MORPHINE. IT DIDN’T WORK SO WELL. IT LED TO A PROBLEM IN THE U.S. THE MORPHINE ADDICTION IN THE 1890s SUPPOSEDEDLY EFFECTED ONE
OF TWO AMERICANS SO WE’RE NOT AS ABOUT AS 1890. BUT THE USE OF INJECTABLE DRUGS IS MORE OF A PROBLEM NOW. WHEN I TRAINED HEROIN ADDICTION WAS COMMON IN THE AREA WHERE I WORKED. THE COMPLICATIONS OF HEROIN ADDICTION AND OVERDOSE DEATH WAS NOT THE BIGGEST PROBLEM IN THAT TIME FRAME. IT WAS INFECTIONS AND PEOPLE WOULD HAVE FOUR HEART VALVE SURGERIES AND THE VALVES GOT EFFECTIVE. THEY PUT A NEW VALVE IN AND THAT WOULD GET INFECTED. AND THEY TRAINED THE CARDIAC SURGEON OF CHICAGO. SO THIS HAS BEEN A HORRIBLE PROBLEM. HOW WE GET HERE IN THIS INSTANCE IS BECAUSE OF THIS COMMON CONDITION WHICH IS PAIN. IN THE U.S., 40 MILLION HAVE SEVERE PAIN AND 8 MILLION REPORT PAIN INTERFERES WITH LIFESTYLE AND THAT WAS A MOMENT TO TREAT PAIN AS THE FIFTH VITAL SIGN. WHEN YOU GO TO THE DOCTOR THEY ASK YOU HOW MUCH PAIN HAVE YOU ON THE SCALE OF 1-10. I NEVER HAVE NO PAIN. THEY SAID SHOULD WE TREAT? NO, OKAY. I’M FINE. IT LED TO MORE TREATMENT OF PAIN AND THIS WAS ALSO THE THOUGHT WAS IT WAS SO SLOWLY ACTING WAS IT GET PEOPLE HIGH OR ADDICTIVE. PHYSICIANS WERE STARTING TO GET PEOPLE ADDICT AND WHEN WE STARTED OUT 75% TO 80% OF PEOPLE GOING TO HEROIN WERE COMING OFF PRESCRIPTION OPIOIDS. NOW IT’S LESS THAN 50%. WE HAVE OTHER BAD ACTORS BRINGING IN FENTANYL TO MAKE MONEY OFF PRESCRIPTION MEDS AND NOW THEY’RE GOING STRAIGHT TO YOUNGER FOLKS GETTING STRAIGHT ONTO HEROIN AND FENTANYL. ONCE YOU TAKE THE DRUGS, YOUR BRAIN IS REWIRED AND IT’S A CHRONIC DISEASE AFTER THAT. THERE’S PAIN AND PLEASURE AS SOVEREIGN MASTERS. THEY’RE THE MOST PRIMITIVE FACTS THAT DRIVE BEHAVIOR. THAT’S WHY WE STAY AWAY FROM INJURY WHEN WE CAN. THE OPIOID SYSTEM IS INVOLVED IN PLEASURE AND PAIN. AND THEY USE SIMILAR PATH WAYS. FOR US TO TAKE ADVANTAGE OF SCIENCE TO BEAT WHAT HAPPENS IN 3400 B.C. WITH THE DISCOVERY OF OPIUM WE HAVE TO DISEN TANGLE THE TWO PROPHECIES. YOU CAN SEVERE PAIN. I DON’T KNOW IF PEOPLE WATCHED THE BOSTON MARATHON YESTERDAY BUT THERE’S A LOT OF PAIN IN THOSE PEOPLE BEFORE THE CROSS THE LINE. IT DOESN’T STOP THEM BECAUSE THE REWARD AND THE CHEMISTRY IN THERE ALL THE ENDORPHINS ARE DRIVING THE SYSTEM SO YOU CAN DECREASE WHAT YOU PERCEIVE IS THE PAIN. THE NERVE IMPULSE IN YOUR KNEES AREN’T AFFECTED THAT MUCH BUT HOW YOU DEAL WITH THE PAIN IS REDUCED BY THE REWARD SYSTEM YOU HAVE. WHEN YOU ADD IN THE OPIOID RECEPTOR THE ANTAGONIST DOESN’T WORK ANY MORE AND IT CAN DRIVE THE ANIMAL TO GET THE PLEASURABLE STIMULUS AND THAT IS BY ADDING IN THE OPIOID RECEPTOR. THE PAIN AND PLEASURE SYSTEM DRIVE BEHAVIOR AND THE OPIOID SYSTEM IS INVOLVED IN BOTH OF THESE. AND THE OPIOID SYSTEM IS NOT JUST USED FOR PAIN AND PLEASURE, BUT UNFORTUNATELY, IT’S ALSO USED IN OTHER NERVE SYSTEMS PARTICULARLY THE RESPIRATORY SYSTEM. THERE’S A PROBLEM WITH THE OPIOIDS IS THEY STRESS RESPIRATION AND YOU NEED LOW BLOOD PLEASURE AND THE DRUGS ON THE STREET THEY’RE CUTTING HEROIN WITH, PEOPLE STOP BREATHING BEFORE THEY FINISH THE INJECT. WE HAVE TO PIECE APART THE DIFFERENT PATH WAYS. AT NIH IN TERMS OF DEALING WITH THE PAIN, THERE’S A LOT OF INSTITUTES WHO WORK ON PAIN ACROSS NIH AND THERE’S A CONSORTIUM THAT EXIST AND WE HAVE AN INTERAGENCY PAIN COORDINATING COMMITTEE WHICH IS AGENCIES AND ADVOCATES AND PEOPLE FROM DIFFERENT COMMUNITIES OUTSIDE THE GOVERNMENT AND THEY WORK TO TRY TO GET BETTER PAIN CONTROL, LESS ADDICTION THROUGHOUT THE COUNTRY AND PUT OUT WHAT’S CALLED THE NATIONAL PAIN STRATEGY THAT IS A POPULATION MESSAGE AND LOOKING AT MANAGING PAIN BY DECREASING THE CHANCE OF ADDICTION. THERE ARE THINGS WE CAN DO TO TURN THE TIDE BACK TO LOOK AT THE INFORMATION THAT’S AVAILABLE NOW. THERE’S A GROUP THAT’S GOT THE FEDERAL RESEARCH STRATEGY WHICH GUIDES NIH AND THE RESEARCH THEY THINK IS IMPORTANT. SO A LOT OF IT IS PREVENTION. THE IDEA THAT THERE’S ACUTE PAIN. WE ALL FEEL ACUTE PAIN AND IN SOME PEOPLE IT GOES ON TO CHRONIC PAIN. SOME OF THOSE PEOPLE IT’S DISABLING. SO THEY NEED SOME TYPE OF TREATMENT TO BE ABLE TO FUNCTION BECAUSE OF THEIR CHRONIC PAIN. AND WHAT WE DON’T UNDERSTAND IS WHY SOME PEOPLE GO INTO SURGERY AND IT HURTS, NO QUESTION IT HURTS, A COUPLE WEEKS LATER, SOME ARE DOING BETTER, THREE MONTHS LATER YOU’RE BACK IN THE GYM AND OTHER PEOPLE HAVE CHRONIC PAIN THAT NEVER GOES AWAY AND REQUIRE QUOTE, UNQUOTE, OPIOIDS. THOUGH THE EVIDENCE IN OPE WROTES HELPS THE CHRONIC PAIN SITUATION WHICH SLIM OR NON EXISTENT. IT CAN HELP INTERMITTENTLY BUT MAY ALSO AGGRAVATE CHRONIC PAIN BECAUSE IF YOU’RE ON OPIOIDS AND TRY TO COME OFF THEM IT THE INDUCE THE CHRONIC PAIN. CONGRESS SAYS MY MOTHER WENT TO THE HOSPITAL AND THEY GAVE HER 180 VICODIN PILLS AND WHY’D THEY DO THAT? THEY WOKE ME MOTHER UP IN THE MIDDLE OF THE NIGHT AND ASKED IF SHE HAD PAIN AND INJECTED HER WITH PAIN MEDICINE. TRYING TO UNDERSTAND HOW WE CAN BEST MANAGE ACUTE PAIN IS IMPORTANT. A AND THE TRANSITION IS IF YOU KNOW WHAT HAPPENS GOING FROM ACUTE TO CHRONIC PAIN YOU CAN PREVENT IT. AT NIH THERE’S WORK ON THE PROGRAM TO TEACH PHYSICIANS ON THE BEST MANAGEMENT TEAM AND LOWERING THE ADDICTION POTENTIAL. AND YOU THINK ABOUT PAIN THERE’S LOTS OF DIFFERENT NODES IN THE SYSTEM. SO IF YOU THINK WAY OUT IN THE PERIPHERY YOU CAN HAVE PAIN AND THE RECEPTORS IN THE SKIN AND APPLYING A LIDOCAINE IS IMPORTANT IN BLOCKING OUT THE PAIN STIMULUS AND HAVE YOU THE NEXT NODE IN THE DORSAL
GANANGLION CELLS HAVE OTHER RECEPTORS. TURNS OUT THEY HAVE RECEPTORS FOR A GROWTH FACTOR WHICH WAS IDENTIFIED AND IT CAUSES FEWERO FEWERONS — NEURONS WERE TARGET AND THERE ARE RECEPTORS ON THE DORSAL ROOT GANGLION AND THEY ELEVATE YOUR PAIN RECEPTION. SO NOW THERE ARE COMPANIES WITH ANTIBODIES WHICH ARE QUITE POTENT AT PREVENTING PAIN AND THAT’S GETTING AWAY FROM THE ADDICTION SYSTEM AND IT GOES TO THE SPINAL SYSTEM AND THERE WITH KNOW AS AN ANIMAL DEVELOPS CHRONIC PAIN SYSTEM THERE’S A PLASTICITY OCCURRING AND THAT IS THE AVENUE WHERE WE THINK WE CAN UNDERSTAND THE BLOCK AND WE MAY BE ABLE TO PREVENT THE TRANSITION IN ACUTE TO CHRONIC PAIN. THEN IT GOES INTO THE BRAVE — — BRAIN AND GETS MESSY. THE THALAMUS IS WHERE THE SENSORY SYMPTOMS CONVERGE AND THE THALAMUS HAS LONG-TERM PAIN THAT CAN OCCUR IN CERTAIN INSTANCES. ONE THING SO KNOW IS THERE IS THIS IDEA, WITH CHRONIC PAIN THE PAIN GETS MORE CENTRAL. AND SOME GET SUICIDE TYPE PAIN IT’S SO HORRIBLE AND YOU CUT THE NERVE AND IT GOES AWAY AND THEN IT GOES AWAY AND GOES TO A GANGLION AND THEN YOU ARE IN PAIN AND IT COMES BACK AND YOU CUT THAT AND THEN IT WINDS UP COMING BACK. THE PAIN SYSTEM CHANGES WITH CHRONIC PAIN. THERE’S LOTS OF POTENTIAL TO THE SCIENCE AND NOW LOTS OF PAIN RECEPTORS WE NOW KNOW ABOUT. WE HAVE EXAMPLES OF PEOPLE BORN WITHOUT A PARTICULAR AREA THAT RECEIVES PAIN AND SOME DON’T RECEIVE ANN — ANY PAIN. YOU WANT TO BUILD A DRUG TO BLOCK THOSE RECEPTOR TO NOT FEEL PAIN, BUT SOMETIMES THOSE WHO DON’T FEEL PAIN ARE IN TROUBLE BECAUSE THEN THEY GET BURNED, THEY HAVE TERRIBLE INJURIES TO THEIR JOINTS AND IT’S NOT AS SIMPLE AS IT OFTEN TIME SEEMS WHEN YOU FIRST GET INTO THIS. IT DOES MEAN THAT THERE ARE WAYS OF MANIPULATING THE SYSTEM AND YOU HAVE TO GET IN THE SWEET SPOT. AND IT WAS FOUND THAT A NEUROTRANSMITTER WAS FOUND DURING THE ACT OF A MIGRAINE. IF YOU GIVE CRG TO PEOPLE YOU CREATE PAIN AND NOW THERE ARE DRUGS THAT ARE AT THE FDA ABOUT TO BE APPROVED AND CAN BLOCK THE HEADACHE IN THIS GROUP OF PATIENTS. SO ANOTHER EXAMPLE OF MOVING OUT OF THE OPIOID SYSTEM TO THE PAIN SYSTEM. SPINAL CORD STIMULATERS AND THE TRANSMISSION OF SIGNALS UP TO THE SPINAL CORD USED FOR A LONG TIME. THIS SHOWS PEOPLE WITH CHRONIC PAIN YOU CAN IMPROVE THEIR CLINICAL OUTCOME. THIS IS SOMETHING A LOT OF PEOPLE DON’T DO BECAUSE IT’S INVASIVE. YOU HAVE TO PUT IT OVER THE SPINAL CORD ITSELF BUT IN A CRISIS WHERE PEOPLE ARE DYING OF OVERDOSE IT’S SOMETHING TO THINK ABOUT WITH CHRONIC LOW BACK PAIN. ANOTHER EXAMPLE OF STIMULATING THE NERVE ITSELF IS JUST APPROVED THE VAGUS NERVE STIMULATOR FOR MIGRAINE. IT’S EFFECTIVE IN CLUSTER AND SOME PEOPLE WITH HEADACHE AND DOES EXTREMELY WELL. THIS STIMULATES THE VAGUS NERVE AND BACK TO THE BRAIN STEM AND SOMEHOW INTERFERES WITH THE PAIN SYSTEM THAT CREATES THE HEADACHES. WE DON’T UNDERSTAND HOW. IN THE BRAIN INITIATIVE WHICH NIH HAS BEEN AN AMAZING PROJECT TO DEVELOP TOOLS TO SEE CIRCUIT ACTIVITY IN ACTION. THIS IS A TRANSGENIC MECHANISM AND YOU CAN SEE THE CELLS LIGHT UP. NOW WE HAVE THE ABILITY TO SEE ACTIVITY IN THE PAIN CIRCUITS IN REAL TIME GIVING US HOPEFULLY NEW TOOLS TO INTERFERE IN THE PAIN SYSTEM FOR HEALTH BENEFITS. IN THE CURRENT ATMOSPHERE WE NEED PATIENTS TO GET THE KIND OF SPECIAL CARE YOU WOULD GET IF YOU HAD A HEART ATTACK OR A SEVERE LEUKEMIA. YOU WOULD GO TO AN ONCOLOGIST OR LEUKEMIA SPECIALIST OR TO A CARDIOLOGIST FOR HEART TROUBLE. PAIN, THERE’S LITTLE ABILITY TO GET TREATED BY EXPERTS. MAINLY BECAUSE IT’S AN A HEARD AREA. — IT’S A HARD AREA AND TO TAKE CARE OF PEOPLE WITH CHRONIC PAIN IS MISERABLE. I USED TO RUN THE CLINICAL SERVICE AT MASS GENERAL AND THE HEADACHE DOCTOR LOST $100,000 A YEAR BECAUSE THE PATIENTS TAKE SO MUCH TIME AND YOU GET BUILD FOR SEEING PATIENTS EVERY 15 MINUTES AND IT’S JUST NOT POSSIBLE. WE NEED TO CHANGE THE SYSTEM SO PEOPLE GET THE PAIN CARE THEY NEED WHICH NOT SOMEBODY WHO IS JUST GOING TO WRITE A PRESCRIPTION WHICH IS HOW WE GOT IN THE TROUBLE IN THE FIRST PLACE. WE NEED PEOPLE TO BE COUNSELLED ON PAIN MANAGEMENT. YOU CAN LISTEN TO SOOTHING MUSIC AND TURN THE PLEASURE BAROMETER UP OR EXERCISE SO YOU’RE NOT STIFF ALL THE TIME FOR BACK PAIN. THERE ARE WAYS TO MANAGE THIS WITHOUT DRUGS AND IF YOU’RE GOING TO GIVE DRUGS, YOU BETTER USE EVERYTHING ELSE THAT’S NOT DRUGS AS YOU DO THAT. WE DON’T HAVE A GOOD SYSTEM STIMULATE U.S. AS A MATTER OF FACT, MUCH OF WHAT HAPPENED IN RURAL AMERICA IS PEOPLE CAME IN AND THEY JUST STARTED PRESCRIPTIONS FOR PAIN MEDS AND THEY WERE BASICALLY CROOKS AND ONE DOCTOR IN VIRGINIA WAS WRITING 1,000 PRESCRIPTIONS A DAY AND HE WAS JUST GETTING PAID FOR WRITING PRESCRIPTIONS. SO THERE’S THE HEAL INITIATIVE HELPING TO END ADDICTION AND LONG-TERM INITIATIVE AND IT’S GOT TWO AREAS. ONE IS TO PREVENT ADDICTION TO ENHANCE PAIN MANAGEMENT AND THE OTHER IS TO IMPROVE DISORDER AND ADDICTION. WE’RE HOPING TO ROLL THESE THINGS OUT. THERE’S A WHOLE OF ACTIVITIES AND EXTRA MURAL PLANS AS WELL. ONE OF THE BIG AREAS WE NEED TO MAKE PROGRESS ON IS TO GET AWAY FROM A SUBJECTIVE PAIN SCALE AND GET TO SOMETHING MORE BIOLOGICALLY RELATED TO THE PAIN. IF WE’RE GOING INTERACT WE NEED READ OUTS AND WE DON’T HAVE THOSE NOW. FOR PEOPLE WHO TAKE CARE OF PATIENTS WITH PAIN IT’S HARD TO UNDERSTAND WHEN THEY’RE COMING TO YOU WITH PAIN VERSUS DRUG SEEKING. SOME DRUG SEEK BECAUSE THEY DON’T FEEL GOOD WITHOUT THE DRUGS. THAT’S HARD TO DISASSOCIATE THAT FROM PAIN. THERE ARE A COUPLE AREAS IN THE FUNCTIONAL MLIs SPACE AND THERE’S NOW A CONSORTIUM AROUND THE WORLD TRYING TO GET PAIN SIGNALS FROM FUNCTIONAL MR. THEY STIMULATE AND ARE GETTING SIGNALS IN THE BRIN OF THE AREAS THAT GET ACTIVATED THAT CORRELATE WITH THE INTENSITY OF THE STIMULUS WHICH IS GREAT. IN ADDITION THEY’RE SEEING AREA ACTIVATED NOT JUST BY THE INTENSITY BUT THE PAIN. THINK OF IT AS TWO ASPECTS. ONE IS STIMULUS COMING IN AND THE OTHER IS HOW DO YOU PERCEIVE IT. THE MARATHON RUNNER THEY DON’T PERCEIVE IT AS BAD UNTIL THE RACE IS OVER. THOSE TWO THINGS ARE IN LOTS OF AREAS TO THINK ABOUT WITH THE GANGLION AND THE SPINAL CORD AND THE DIRECTOR’S FUND IS GOING TO LAUNCH A PROJECT TRYING TO UNDERSTAND THE PREDICTIVE MARKERS FOR THE TRANSITION FROM ACUTE TO CHRONIC PAIN WITH THE HOPE WE CAN INTERVENE AND PREVENT SPINAL PAIN. YOU CAN SEE WE’RE ATTACKING THE OPIOID EPIDEMIC AND SOME SHORT TERM AND SOME LONG TERM ON THE PAIN SIDE AND ALSO ON THE VICTIMS SIDE. WITH THAT, I WANT TO THANK EVERYBODY FOR THEIR ATTENTION. I CAN TAKE ONE QUESTION AND IN THE GOT TO RUN. >> ARE YOU LOOKING AT GENDING DIFFERENCES IN PAIN TREATMENT AND THE BIOLOGICAL DIFFERENCES? >> CHRONIC PAIN IS MORE PROMINENT IN WOMEN. IN THE 1890s THE ADDICTION WAS PRIMARILY IN WOMEN. HEADACHE WAS MORE COMMON IN WOMEN AND OPIOID, HEROIN USE, WHEN I WAS TRAINING WAS ALMOST ENTIRELY MEN AND WITH THE PRESCRIPTION OPIOIDS, UNFORTUNATELY, THE WOMEN AND MEN WERE EQUAL. THE GENDER ISSUES ARE CRITICAL HERE. >> REGARDING THE PAIN SIGNATURE AND THE BIOLOGICAL MARKER, SO THE GOAL IS TO TRY TO DEFINE SOMETHING UNIQUE TO PAIN AND THEN FROM NORAH’S TALK WE KNOW THERE’S OVERLAP BETWEEN THE A ED BRAIN AND CHRONIC PAIN BRAIN. THAT WORK IS GREAT BUT IT’S ONLY FOCUSSING ON THE PAIN BRAIN. WHAT IS THE THINKING ON THAT FROM YOUR PERSPECTIVE? >> WE BELIEVE WE NEED A MARKER TO TEST FOR THE EFFICACY OF A NEW THERAPY. CAN WE GET SOMETHING THAT IS MORE PREDICTIVE OF WHETHER A TREATMENT IS WORKING AGAINST PAIN THEN SIMPLY ASKING SOMEBODY. WE’RE AT THE VERY PRIMITIVE LEVEL. NOT AT THE LEVEL OF TRYING TO DISTINGUISH PAIN, PLEASURE IN AN OPIOID ADDICTED PERSON. THAT WOULD BE REALLY COMPLICATED. [QUESTION INAUDIBLE] >> THAT’S A GOOD POINT FOR PEOPLE WITH CHRONIC PAIN. >> WHILE OBJECTIVELY MEASURING THE PAIN, DO YOU THINK WE pPROBABLY NEED TO GO ALL THE WAY IT THE BRAIN OR MAYBE YOU WOULD PREPARE ALL SIGNALS LIKE PHYSIOLOGY. >> THERE COULD BE DIFFERENT THINGS TO MEASURE AND THE AUTONOMIC ACUTE PAIN SHOULD BE EASIER TO GET TO THAN THIS. WITH PEOPLE IN BACK PAIN INSTEAD OF ASKING EVERY THREE MONTHS YOU CAN BASICALLY MONITOR HOW THEY WALK OVER MONTHS AND ALSO KNOW IF THEY’RE PLAYING GOLF WITHOUT TELLING YOU. >> I WAS WONDERING, IN THE OPIOID OVERDOSE IF IT OVERLAPS WITH THE MAP OF PAIN WHICH IS WELL KNOWN IN A PHYSICIAN’S RECORD. IF THE MAP OF PAIN OVERLAPS WITH THE MAP OF OPIOID OVERDOSE? THE UNITED STATES MAP. >> IT DID UP TO FOUR YEARS AGO AND NOW IT’S CHANGING BECAUSE PEOPLE ARE GOING STRAIGHT TO HEROIN AND BYPASSING PRESCRIPTION OPIOIDS. NOW IT’S DIFFERENT. NOW IT’S MOVING INTO CITIES MORE AND THE RURAL AREAS. THESE PEOPLE WHO ARE DEALERS ARE REALLY BAD ACTOR. THEY’LL GO ANYWHERE TO MAKE MONEY AND THEY GET PEOPLE HOOKED. THEY’LL MAKE MONEY. >> WHEN A PATIENT GOES TO THE PAIN DOCTOR AND THEY ASK HIM HOW MUCH PAIN DO YOU HAVE AND IN ORDER TO GET THE MEDICATION THEY SAY THE PAIN’S 10. BUT IF THEY GO TO THE DOCTOR TO GET RID OF THEIR ADDICTION AND ASK HOW MUCH PAIN DO YOU FOR A PROGRAM, IT’S TWO. IS THERE ANY WAY WE CAN USE A MEASUREMENT TO PINPOINT AND HELP THE DOCTOR TO KNOW HOW MUCH PAIN THE PERSON’S IN? >> THAT’S THE PROBLEM. WE DON’T HAVE THE ABILITY. THAT’S THE HOPE BEHIND THE WAIVER STUFF. THERE’S NO REASON WHY WE CAN’T LOOK AT THOSE WHEN WE HAVE BETTER TOOLS. >> THE MAIN KILLER IS FENTANYL. IT’S BELIEVED THE FENTANYL IS COMING FROM CHINA. [APPLAUSE] >> ARE THERE OTHER QUESTIONS? >> I’M AN INVESTIGATOR AND HAVE BEEN TALKING ABOUT DOING A RETREAT AT THE INTERSECTION OF PAIN AND ADDICTION AND WE USE MODELS OF REWARD. MY FINAL QUESTION WOULD BE WHERE DO YOU THINK WE SHOULD WORK AT THE INTERSECTION TO GET PAIN AND ADDICTION COMMUNITIES TALKING TO EACH OTHER. DO YOU THINK TESTING PAIN IN INDIVIDUALS WITH SUBSTANCE USE DISORDERS WOULD HELP US MOVE FORWARD. WHERE DO YOU SEE THE BEST PLACE FOR GROWTH WHERE WE CAN WORK WITH EACH OTHER IN THE UNIQUE SETTING IN THE INTERMURAL PROGRAM? >> I VIEW IT FROM IN TERMS OF THE BASIC UNDERSTANDING OF THE CONNECTIONS BETWEEN THE PLEASURE OF PAIN CENTERS. TO THE DOPAMINE CELLS ARE ACTIVATED BY PAINFUL STIMULI. UNDERSTANDING THE DIFFERENCE CELLS AND THE PROJECTIONS AND THE BASIC ASPECT OF RESEARCH AND ANOTHER IMPORTANT ASPECT OF RESEARCH THAT WHEN WE DO ADMINISTRATION OF A DRUG AND THE CHAN CHANGES HAVE BEEN LOOKED AT IN THE AMYGDALA AND IT TRIGGERS CHANGES IN THE EXPRESSION OF THE RECEPTORS SIGNALLING. THAT SAME PROCESS IS THE SAME ONE THAT IS IN MEMORY AND SYNAPTIC EFFECTS AND WE CAN PREDICT THE SAME MOLECULAR TARGETS WILL BE THERE AND BASED ON THE RESEARCH AND THE EXPERTISE IT WOULD BE A FASCINATING AREA OF RESEARCH. TO WHAT EXTENTS THE CHANGES ARE ENGAGED FOR ADDICTION AND PAIN. FROM THE PERSPECTIVE OF CLINICAL RESEARCH TO THE QUESTIONS OF FOR EXAMPLE, WHAT IS ULTIMATELY THE NEUROCIRCUITRY ASSOCIATED WITH PLEASURE, WE DO A LOT OF RESEARCH IN ADDITION TO CUES. I’M TRYING TO MAP OUT THE DIFFERENCES. THERE ARE SO MANY QUESTIONS THAT THE ANSWER WILL COME FROM PUTTING PEOPLE TOGETHER AND SEEING GREATER OPPORTUNITY ON ADVANCING THE FIELD FORWARD. AND AGAIN IT’S THE ISSUE OF BRINGING PEOPLE TOGETHER AND HE CAME AND SPOKE TO OUR GROUP AND HE WAS PRESENTING DATA AND HE WAS SHOWING THAT THE RECEPTORS PREVENTS TOLERANCE TO OPIOIDS OR ENHANCES THE ANALGESIC EFFECTS. IT BLEW MY MIND. THEY WERE DOING RESEARCH RELEVANT TO THE OPIOID CRISIS AND TO START WITH TO CONNECT THE POINTS YOU HAVE TO BRING PEOPLE TOGETHER AND I THINK THERE’S MANY OPPORTUNITIES. >> TO WHAT EXTENT IS THIS A GLOBAL PROBLEM? >> WE’RE NOW SEEING A MASSIVE PROBLEM IN VANCOUVER. THEY’RE AFFECTING CANADA. I DON’T THINK AT THE SAME EXTENT AS US AND THE UNITED KINGDOM IS REPORTING INCREASES IN OVERDOSES. NORTHERN PARTS OF EUROPE. NOW WITH THE WEB AND THE WAY THE SYNTHETIC OPIOIDS ARE COMING, ONE MAIN SOURCE IS THROUGH THE MAIL. YOU CAN THINK ABOUT THE POTENTIAL OF DISSEMINATION OF GLOBALIZATION. THEY’RE EASY TO SYNTHESIZE AND EASY TO SNEAK IN AND HIGHLY ADDICTIVE AND ENORMOUS PROFIT. IT FORCES PEOPLE TO DO REALLY MEAN THINGS AND BAD THINGS. I BELIEVE IT’S INCREDIBLY IMPORTANT THE OTHER COUNTRIES LEARN FROM THE UNITED STATES TO PREVENT THIS EPIDEMIC FROM DISSEMINATING. OTHERWISE IT’S LIKE AN INFECTION HOUSE DISEASE. IT WILL GROW BEYOND THE UNITED STATES AND CANADA. >> HOW DO YOU THINK OTHER COUNTRIES SHOULD GO ABOUT DOING THAT AND WHAT MEASURES SHOULD CERTAIN COUNTRIES TAKE TO LEARN FROM THE U.S. AND CAN YOU TALK A LITTLE BIT ABOUT THE UNIQUE METABOLISM OF OPIOIDS AND HOW THEY STAY IN THE SYSTEM THAN TYPICAL DRUGS AND DOES IT MAKE IT DIFFICULT TO TREAT ADDICTION AND TRY TO KICK PEOPLE OFF ADDICTIVE BEHAVIORS. >> IN THE UNITED STATES WITH CANADA HAVE HIGH RATES OF PRESCRIPTION PRACTICES FOR OPIOIDS. IN MEXICO WHERE A LOT OF THE HEROIN IS PRODUCED HAS A LOWER, MINIMAL OPIOID PROBLEM IN THE BORDER STATES. THEY HAVE NOT BEEN EXPOSED AND IT WAS A GOOD BREACH TO ENTERING AND GETTING THE COUNTRY READY FOR EXPANDING OPIOID MEDICATIONS. HEROIN WAS PREVALENT IN THE MARKET AND BEING ABLE TO MINIMIZE THE AVAILABILITY AND ACCESS TO THE DRUG DETERMINES HOW LIKELY PEOPLE ARE TO GET EXPOSED. IN TERMS OF PREVENTION, ONE OF THE LESSONS WE WANT TO LEARN FROM WHAT HAPPENED TO US IS YOU HAVE TO BE CAREFUL IN HOW YOU PRESCRIBE OPIOID MEDICATIONS IF YOU HAVE ACUTE OR CHRONIC PAIN, IT HAS TO BE UNDER LIMITED DOSE DURATION AND EXPOSURE AND CLOSE OVERSIGHT AND WE BECAME CMPLACENT. AND COUNTRIES HAVE BEEN FIGHTING LIKE WALTER MENTIONED ABOUT THE PROBLEM OF OPIOIDS IN CHINA. THERE’S NOT ZWLUFT ONE CAMPAIGN. NOT WHAT IS DEALING WITH OPIOIDS BEING MORE ADDICTIVE OR DANGEROUS THAN SOMETHING ELSE. THE DRUGS THAT ARE SHORT LASTING. FENTANYL HAS A SHORTER SHELF LIFE THAN OTHER DRUGS. IT’S NOT THE DURATION OF THE DRUG IN YOUR BODIES. THE SPEED AT WHICH IT INTERACTS WITH THE RECEPTOR AND THE POTENCY DETERMINES ITS EFFECTIVENESS. MARIJUANA HAS A SLOW RELEASE. >> DO YOU THINK THE FDA COULD HAVE BEEN MORE PROACTIVE IN REGULATING OPIOID USE? >> I THINK WE COULD HAVE BEEN MORE PROACTIVE. I THINK THE WAY I VIEW IT IS WHERE WERE THE HOLES THAT ALLOWED THIS TO HAPPEN AND LOOKING AT IT WOULD SAY YOU NEED TO HAVE BEEN MUCH MORE OBSERVANT OF FOLLOW-UP OF THE PATIENTS NOW THE FDA IS DEMANDING. IF YOU HAVE AN EXTENDED RELEASE FORMULATION YOU HAVE TO FOLLOW INDIVIDUALS TO SEE IF [INDISCERNIBLE] THE COMPOUND AND ONE OF THE OPIOID MEDICATIONS WAS DISAPPROVED BY THE FDA. YES, IF WE HAVE KNOWN, WE SHOULD HAVE BEEN MORE OBSERVANT AND SHOULD HAVE LOOKED AT REGULATION IN ADVERTISEMENTS FROM THE PHARMACEUTICAL INDUSTRY AND WHEN I WAS A STUDENT THE BIG MEETINGS WERE TO SUPPORT THE PHARMACEUTICAL INDUSTRY AND THEY WOULD COME TO THE HOSPITAL TO ADVERTISE ABOUT THE MEDICATIONS AND GIVE US SAMPLES TO THE PATIENTS. AND SOME PRACTICES THAT SHOULD HAVE NEVER HAVE BEEN ALLOWED TO HAPPEN, HAPPEN. NOW WE NEED TO LEARN AND STOP IT. SAME THING PHYSICIANS. THEY SHOULD HAVE NOT BEEN ACTUALLY SO COMPLACENT. YOU’RE NOT GOING TO ADDRESS THE NEEDS OF A PATIENT AND YOU GIVE THEM A PRESCRIPTION AND NURSES DON’T GET TRAINING ON ADDICTION AND PHARMACISTS, DENTISTS. MULTIPLE HOLES AT MULTIPLE LEVELS THAT ALLOWED THE CRISIS TO HAPPEN. >> WHAT ABOUT THE AVAILABILITY OF NALOXONE ACROSS THE BOARD? IF A PATIENT IS OUT OF THE STREET AND SOMEBODY’S DYING, HOW DO YOU — >> THE BEAUTY OF A PRESCRIPTION YOU DON’T NEED A WHOLE PRESCRIPTION BUT I’M A STRONG PROPONENT OF GIVING NALOXONE OVER THE COUNTER AND MY SPSHTH PERSPECTIVE PERSPECTIVE IS WE THESE TO SAVE AS MANY LIVES AS POSSIBLE. IF YOU HAVE IT OVER THE COUNTER AND ARE NO LONGER BEING REIMBURSED, WILL THAT LIMIT THE NUMBER OF PEOPLE WHO CAN GET AS ACCESS. FOR SOMEONE PAYING $150 IT MAY LIMIT THEIR WILLINGNESS TO GET IT. WE’LL FIND OUT. >> YOU MENTIONED NEW THINGS WE HAVE LEARN FROM THE OPIOID ISSU ISSUES WE ARE INCORPORATING MOVING THIS FORWARD TO PREVENT THIS FROM HAPPENING. FROM THE PAIN SIDE OF VIEW, ARE THEY ALSO INCORPORATING THE NEW MEASUREMENTS WITH THE DEVELOPMENT OF NEW TARGETS FOR PAIN BECAUSE THE OVERLAP IS CONCERNING TO ME. THE TREATMENT THE ANTAGONIST, WOULD IT BE PROBLEMATIC IN THE FUTURE. WHATEVER IT IS WE FIND THAT MIGHT BE A MAGIC BULLET FOR PAIN, HOW DO WE PREVENT IT FROM BECOMING ALSO LOOKING AT THE NEXT EPIDEMIC. >> NO, THERE’S BEEN AN ENORMOUS AMOUNT OF ADVANCES THAT ALLOW YOU TO PREDICT WHEN A DRUG WILL HAVE THE LIKELIHOOD OF ADIRECTIVE POTENTIAL. AND SOME ARE UNLIKELY TO HAVE AN EFFECT. THE AMYGDALA IS MORE LINKED WITH EMOTIONAL. SOMETIMES WE FIND THAT DRUGSZ DRUGS DRUGS WEREN’T ACTIVATING WERE HIGHLIGHTING WHY EVERY SINGLE DRUG THAT IS GOING TO HAVE A CENTRAL EFFECT REQUIRES THE FDA TO DOCUMENT IT’S NOT REGARDING THIS ZONE TO DETERMINE IF WHAT’S ITS SCHEDULE IS AND WHAT PRECAUTIONS YOU SHOULD TAKE. I WONDER IF YOU CAN TALK ABOUT MENTAL PAIN, MENTAL DISORDERS AND SUFFERING AND HOW PEOPLE ARE USING THIS TO SELF-MEDICATE AND THERE’S A DEEPER ISSUE AND WE HAVEN’T BEEN EDUCATING PEOPLE ON THE ACCESS. >> IT’S A GOOD QUESTION. AND RESEARCHERS HAVE ALREADY COMMENTED ON THE OVERLAP WITH PSYCHOLOGICAL AND PHYSICAL PAIN. THERE’S A LOT OF OVERLAP. THAT COULD EXPLAIN WHY, FOR EXAMPLE, 50% OF THE OPIATE PRESCRIPTIONS ARE PRESCRIBED TO PEOPLE WITH A MENTAL ILLNESS, MOST WITH A MOOD DISORDER. TO ME IT’S TELLING YOU SOMETHING FUNDAMENTAL. THOSE WITH A MOOD DISORDER ARE A HIGHER RATE OF SUFFERING FROM CHRONIC PAIN CONDITIONS. WOMEN ARE MORE SENSITIVE AND THAT IS RELEVANT BECAUSE IF WE WANT TO UNDERSTAND AND PREVENT PAIN WE NEED TO HAVE A COMPREHENSIVE UNDERSTANDING IN WHAT MAKES YOU VULNERABLE AND ONE IS BEING A FEMALE AND CATATHOPHIZING MAKING YOU MORE LIKELY FOR ADDICTION. >> THANK YOU VERY MUCH.

3 comments

  1. I'm so sick of hearing this bullshit, there's NO OPIOID/OPIATE EPIDEMIC! Alcohol kills way more people and destroys way more families. How many wives get beat by a husband high on Heroin?Anyone who says there's an opiate epidemic is a complete liar. Where were all these problems when opium was legal and found in most homes in one form or another? The ruling class CREATED ALL OF OUR PROBLEMS! I looked in the Bible(only warns about ALCOHOL), and I looked at the Constitution, CANNOT FIND where the Government got the power to control what YOU put in YOUR body, that means the Government acted ILLEGALLY when it started the drug war. The W.O.D. is the root of ALL drug problems. It's all bullshit, just lies, the W.O.D. is what's destroying America, not the drugs themselves.

Leave a Reply

(*) Required, Your email will not be published