In the 2017 lecture series on neuror neuror neuroscience and society. Our first lecture on the brain and video games was held in lecture in r third september will be on meditation. O please keep an eye out for the announcement date. The Dana Foundation is a private supports brainat research through grants, publications, and educational this one. Ike weve last five years, partnered with them to present n annual lecture series on neuroscience and society. This is the 20th lecture in the series. Ere grateful for the Dana Foundations support of this series and for deborahs the series in our scientific responsibility, human rights, and law program. Deborah. That, charlie, and welcome. It seems to me as though hardly not goes by that there is some story that i see either in he newspaper or on the evening news about the opoid crisis. Thinking about that today and leafing through the front sure enough, on the page of the metro section of the Washington Post is a story how of maryland and virginia along with washington getting yor are together to form a combined database to keep an eye on gettingtions and who is these drugs. Day. Ts just another and then a few days ago, that dy sent me something said that in a small town in 392it, west virginia, where people live, a pharmacy there million pills of opoid painkillers. 92 million seems a lot for a of 392 people. So this theres really a very on. Problem going we are going to address it tonight. It from several different points of view. Way, when were done, i want you to know that we have a reception planned. End of this. So tonight were going to look view of an eagles eye a more closedemic, in view from the National Drug abuse and then the from Karen Drexler from va about possible treatments. Professorspeaker is a of medicine at the university of california san francisco. Specializes in Community Medicine and treating diseases and poverty. Leader in the hiv aids at emic in the early days the time hes going to talk early days. To talk to us about this problem tonight. Dan . You. Hank the ere a direction to get next slide up . There we go. Typical academic and i cant my begin to talk until slides are up. A little lost without them. Everyone. Dan ciccarone. Doc so myly community erspective is one of trying to see ways towards community health. Started with the hiv epidemic ut found by way to drugs about 17 years ago, the drug epidemic. Here tonight to pills heroin and fentanyl. Lets try again. Im going to go through some ata on the opoid overdose epidemics comparing prescription ills with heroin, looking at demographics and epidemic curves. The elicitly t fentanyls. D got it. Most of what im presenting is but a y available data little comes from my study, transition, founded by the National Institute of institute of al drug abuse. For the First Time Since 1993, u. S. Death rate has gone up year to year. The height of the hiv aids epidemic. Ere we have the ten leading causes of death as of 2015. Heart disease and cancer are the in the room. Ants one went up. One down. Go to number four, unintentional injuries, theres up, 2014 to 2015. We were shocked in 2011 to find of the leading causes of Unintentional Injury crossed over with drug and motor the rise the le accidents was on decline. This is a graphic from the new york times. Katz on rking with josh this. Overdoses, drug poisoning overdoses, the number of deaths accidents,ceeded car even hiv. Ce, and you can barely see the hiv there. I apologize. A steep rise up. 1993. Ng around peaking around 1993. And then declined. From epidemic, drug poisoning, epidemic, opoid epidemic to crisis. At hospitalization data, his is the curve for the opoid overdose epidemic. Dramatic rise up. And some good news. Plateauing, perhaps even a decline post 2011. Based on the is good work were doing to restrict excessive prescribing practices. Unfortunately, this is now eroin overdose hospital admissions dramatic increase up since 2008. In necessarily the magnitude this slide but that steep curve that has me concerned. Year, no end in sight. Heroin related overdose . Three possibilities. Theres evidence that the number of heroin users is rising. Nd theyre coming from two paths. One is coming from opoid pill isendency and finding heroin more available and cheaper as replacing their high level of heroin. Endency with others are coming to it straight away now. Its cheap. Pure. Good. Everywhere. The supply has changed dramatically in the last few years and the availability has up. Places like burlington, vermont re not supposed to have good heroin and they do. In terms of the transition, my written stories, papers on this. Intertwined epidemics. We used that term as early as 2012. Transition back and forth and thats because opoids are treated equally in the body. We also wrote a story about they on heroin and how transitioned. And younghe new users users telling the story how they started with pills and moved to heroin. Is a picture i took in an philadelphia to symbolize the pill to heroin intertwining. Data from my group looking at comparing the demographics by age for these epidemics. Heres the pill overdose problem. Predominantly, this is older age data, group. Heroin is a younger age group. If you want to show evidence for epidemic, show a rise in problem among young people. It. E we have but if we shift this over, we see some evidence of the transitioning the heroin. Opiate pills and to he opiate overdose year year rate goes down, you can see from the blue to the green, we overdose is in going up in that same age 2012 to 2014. We see a hic region, starker difference. Even across the country for a long period here. Think its worse in appilachia but they are more or less even. Ut heroin is dramatically different. The northeast has had a problem generations but the midwest, the second line, the now ine which is highlighted going from low levels of heroin overdose. Disparity that is not explained by a simple heroin transition. So in addition to that story, we have to tell another story. Heroin is itself becoming a more dangerous drug. It is being contaminated with such as fentanyl and received orm thats very little press. Fentanyl is integrated into the heroin supply. You dont ask for some funny street name for this new drug. Heroin. Nd buy and the heroin you get in that right town and the in massachusetts, for example, oure going to get fentanyl contaminated heroin. Its a potent synthetic opoid. 100 times more powerful than stronger nd 30 times than heroin. Is a long wave in late 2013. Manufactured pharmaceutically created. This implies that there may be a heroin plus e fentanyl as the new heroin forward. In addition to the main chemical which is fentanyl, theres at two dozen analogs and this theics even like synthetics. The big bad boy were worried about is carfentanil. A thousand x morphine. 3 to 400 times as strong as heroin. This is just not meant for human consumption. Ts a large animal pain reliev reliever. So if your elephant has a need. M, thats what you the dea would like to tell us i have no privileged the dea will ut ell us that the illicitly manufactured fentanyl are coming china to north america. The heroin is through Mexico Cartel distribution. Wheres it going . These bottom seven states are laces that have high fentanyl supply according to the National Drug seizure data nd high rates of synthetic opoid deaths. Appilachia, up to new england. So presenting one slide on one reason why we got here. Supply side theory. Hen morphine and heroin were promoted as pharmaceuticals, they were quickly adopted because they worked and did what wanted them to do but drugs. Came problem with have novel drugs Technological Advancements and needle. Dermic weve had waves of heroin, use, isuse, and abuse over the generations. Some of which have been cultural. Some of which have been related new sources. O the vietnam era heroin epidemic. Devastated u. S. Cities. That was a new source of heroin southeast asia. The colombian heroin wave came new cartels brought in a product. They were known for cocaine but 1992. Ht in heroin in now we have the opoid pill problem. A novel form. Think about the extended release capsules butapsule easily abusable. Heroin is coming in now in the 2000s, new source for them. Havent spent a lot of time talking about it but mexico is highlypotent heroin thats never been seen before. Are also coming in, a advancement in that its highly potent and is a heroin. For theres other consequences besides overdose in this opoid injecting drugs leads to Infectious Disease risk. Viruss, hepatitis c and hiv. E should be mindful of the severe hiv , the outbreak in scott county, indiana. Be concerned o about bacterial infections. Of suffering. Ot they cause a lot it costs us a lot of money. All of these things are preventible. Of what my research is to talk with users. Pain, thebers hide the lived experience, the resilience, the coping thats oing on among the using population. We meet with users in the street. We watch them as they prepare inject. Rugs and all the while, fascinated by the new chemicals that are out there. Forms. Ome in new new colors of powders. New forms of powders. Bright tions, this yellow solution when i first saw it it freaked me out. Never seen it before. Heroin for 17 years. This is quite like the synthetic it freaks me out, imagine what the users are going through in terms of trying to adapt to new thing thats out there. They want our help. Provide it. S to so in summary, is this one or three . Im proposing to start them. Ting we need to treat heroin and differently than we treat prescription pill problems. He supply trucks can lead to epidemics. Unfortunately that does not genie oing to put the back in the bottle and that supply control is the only answer. This is an epidemic of were proportions as besting the hiv epidemic at its of e but its also a crisis epic opportunity. E turned that hiv epidemic around. Look at that dramatic drop down. The affect of cultural,te Government Social intervention treatment and prevention. It worked for the hiv epidemic the heroin work for well. Entanyl epidemic as you should not treat them the same anymore. Ontrolling prescription pill practices, prescribing practices, we can do. Out there. Ort its beginning to work. We need better surveillance, we treat this as a poisoning epidemic. Were treating it as a drug epidemic. Bodies. The the dead bodies as they lie. Ere not testing the drug adequately and informing the public adequately. About py to talk more that in the question and answer period. Evidencebased treatment. Bupinorphiee. He comprehensive Addiction Recovery act is good. But its not enough. Its enough. Y we need faster responses to overdose. Naloxone works. Needs to be not just in the hands of paramedics. Now its in the police tool belt. Great. We need to get it to the users and their families. To be this generations epipen. We tend to think of reduction as aiding and abetting drug users in the political sphere. Saves lives and can be a bridge to Clinical Care for the eatment affected individuals and that Public Safety and health new mantra, s the this can happen. We need to work with the criminal justice side of things Public Health side of things. Top treating it as the special privilege of the criminal justice folks and injured bodies Public Health. Both sides need to work together. End. Here ill i want to acknowledge jay unick maryland niversity of who is the statistician on this project. Your kind or attention. Applause] that was a good intro for our next talk which will be government and im anxious for you to hear how much the government is doing. Of speaker is the director the National Institute on drug abuse which is one of the institutes of health. She has been a true pioneer in the physiology, the harmacology of drugs of abuse and she will tell us a bit about hat those drugs are and what doing. Fice is good evening, everybody. Its a pleasure to be here. I think that ive been here times. Last time it was actually we were discussing the issue of how although the changes in policies was going to affect the consumption of the potential negative effects and today were crisis about worse weve ever seen in the United States that relates to a drug. Interesting about these crisis actually which is very tragic is number one first of from any other epidemic that we have in the past this one basically came out healthcare system. Nd it came out with very good intentions which were to treat patients suffering from pain. This was this can be a particularlyisease in a severe state and it was recognized that actually there patients werethat not being properly treated for their pain so in the late 90s in beginning of 2000, it was decided that this would be the treatment. N and among the many actions that joint ace was the commission and that you treat it. This was coupled with a very, emphasis in the need to treat patients at the same that they were limited that eutic interventions can be used for pain resulting expansion in prescription of opoid medications. In the past theres been a lot about use of opoids for the treatment of pain because of the fear that patients will addicted. That shifted dramatically at the 2000s with the very, very strong advertisement pharmaceutical industry to encourage physicians to prescribe opoids with the notion taught in medical school and this is taught until recently that if thank you have to becomere not going addicted to your pain medications. We as physicians became very what lly confounded about we have learned in the past that addiction and e now we needed to treat them. Unfortunately, the numbers of physicians started to prescribe opoids, it became clear that was not the case. And as you look at the numbers backwards, its always easier to but in things backwards 2003 they were showing me the results of monitoring the future. Monitoring the future is a survey that we do with teenagers. Attention my immediately in 2003 is that the of prescription opo vicoden was numbers, we started to realize there was massive over prescription of opioids across all ages. It was like people werent listening to us. It was at the same time an immediate counter reaction. The proper treatment of patients with pain we start to see numbers like this one. My god, we have a serious problem. We see numbers like this. In particular, you can see over there in the appalachian region. We still see that. In the past, theyve not seen it. Were starting to see that it is driven by the emergence of not just pure heroine, but sentinel and synthetic opioids. That is an avalanche of overdoses and death. There are multiple conditions. Variety. Ide the opioid receptors. They have them all over our body. Receptors are actually associated. Seeing positron admission tomorrow. Did the color scale. They engage in our ability. It is actually fundamental for our ability. There were opioid receptors. It is fundamental for the emotional negative reaction that we get with pain. In that area is also loaded with opioid medications. With opioid medications binding to these receptors, it inhibits the perception of pain. Or an emotional reaction. The reason why opioid medication is the most effective medication that you can have for addressing severe acute pain. And it is almost immediate. Something that you may actually want to disrupt and save your life. I dont know if anyone of you has been given that. I have been in a car accident. The pain was so intense. And then they gave me an opioid. It is a sense of euphoria and relaxation. That is why these jobs are very problematic. They are not just located in the pain centers, but they are located in that area there. In this region is one of the most important regions and professing pleasure. They activate that pleasure center. Opioid medication can be among the most rewarding and most addictive. The location in the brainstem. It is responsible and loaded with opioid receptors. Breathinglly inhibit and that is why you can ultimately die from an overdose because it stopped breathing. This is the reason why opioid medications are far from ideal as treatments. Withhe problem emerges chronic pain. You have pain that lasts for more than three months. It rapidly becomes tolerant. It means that you need higher doses in order to achieve the same level of panacea. The higher the likelihood you become addicted. This is the effective opioids in the brain. Factoring in for pain, and the operation in the brain center. That is why these medications are far from idl ideal. The higher the dose right there, and the greater risk of. Verdosing the generation of these epidemics. And it is in 2013 Something Like in thelion prescriptions United States. The elderly americans, 30 of them suffer from chronic pain. In no way does it justify the massive descriptions. These were overprescribing the same thing. And that lead to addiction. So you generated prescription opioids from those votes. It able that were given these medications. And then those that actually started to experiment with these roles. By that lack of control. They are trying to actually train them in proper prescriptions. There are construction practices. When you make these medications with other medications. The amount of opioids being described. In the United States, the rate of death is that it is almost constant. 2000 people dying every year. The number of people have basically quit revolt. So what is driving this . This pure heroine that is a different population. Seeing other areas affected the most. Meantime, we are seeing that the heroine is being laced with fentanyl. As we have heard before, its extraordinary potent. That is what is driving the massive amount of Overdose Deaths. The heroine was deployed from mexico. Statesoine in the united , it started in states where they have the largest problems with prescription opioids. Those it became addicted to the prescription opioids, it was cheaper and easier to go to heroine. Those cases are emerging from individuals that became addicted to prescription opioids. This is important to address because what you dont want to is we actually want to contain the heroin epidemic and make prescription opioids more available. What is leading people to change is that they are very hard to get it. That is the correct answer. In order to address it, we shall event abuse of prescription opioids. They are not going to transition to heroine. The numbers that you so in terms of how it becomes we know from any drug that is out there that it plays an important role. The issue about fentanyl that is coming from china is that it is it can actually bring deposes a small doses tremendous amount of challenge. You carry this very small amount of drug that has a multiplicity of doses. It poses a tremendous challenge. They associate with the overdose. We address it using science. We can provide the means to actually control that problem. It is not any different from the opioid crisis. We need to understand the root cause of the problem. It is estimated that the united , it is moderate to severe. That is one area where we need better treatments. It designs strategies. They are going to overdose again. It is very useful. Pain, we have an incredible opportunity. There are people suffering from pain. , they pourars millions of dollars to develop an opioid medication. They disenfranchise themselves from the development of pain medication. Ability to identify the threedimensional structure, they are able to identify the twoptors that have seen of them appear to be particularly relevant. This is necessary for analgesia. So the g protein is one that is associated with analgesia. What pharmaceuticals are now doing is developing medication that do not engage with the notion that these medications will be useful for pain with overdosing. I will be donning in one of those compounds. In many senses, it is almost impossible. It is getting to the brain so rapidly. The overdose with treatment, they can protect them for future overdoses. Veryhree medications useful. They prevent relapses, they prevent but they are not being used. 15 of individuals in the United States can benefit from medication are getting it. Multiple reasons why that is the case, it is a lack of infrastructure. The medications that will comply. Resulted in a medication that requires Administration Every six. Offacilitate the compliance those addicted to the opioid medications. This intervention would be useful. For treating those that were addicted. And with that, i want to underline some of the documents on any information regarding the research programs. Thanks very much. This has not been a real cheerful session. Of you arethat a lot very interested. There was a very high attendance. I am hoping her next speaker gives us a little cause to walk out of here with a little bit of hope. Our speaker is Karen Drexler. The National MentalHealth Program director for addictive disorders. Should know more about misuse of drugs than the veterans administration. Dr. Drexler is certified in both psychiatry and addiction medicine and will talk to us about treatments. Dr. Drexler thank you to the aaas. I am delighted to give you a third perspective. I still practice with the atlanta v. A. Medical center. I practiced most of the last 25 years. I have been working in the office and washington, d. C. Doing Addiction Treatment policy. To be a consumer of science on two levels. They have done a terrific job of that. Cicconentioned as dr. Also spoke about, it begins with prevention and the signs to enforce the policies about it. A little more on the side of the art of medicine. It is cooperative when we are working at our best. I would like to share a case example about 10 years ago. That story. She is a veteran. This could be any one of us. A very hardworking and licensed professional nurse who was referred for Substance AbuseDisorder Treatment after an overdose. This is the culmination of prescription opioids and other controlled substances. She injured her back at age 34 and was treated with opioid pain medication. She had a series of reinjuries with that. As multiple providers and was described, her drug hunger became greater. She ended up buying some pills on the street and ended up with an overdose. Prescription opioid disorder, if they are taking opioids as prescribed, we dont include the increase intolerance or the withdraw symptoms as criteria for making it a disorder diagnosis. She had most of these symptoms. She had a crazy or strong desire. When it was hazardous or too intoxicated to drive. She had difficulty cutting down. She was spending a lot of time figuring out how to get her next dose of opioids and continued to use it despite knowing there were causing major problems. After the overdose, her primary care provider said i will not prescribe opioids for you unless you go to the Substance Abuse treatment program. Pain the 1990s, opioid prescriptions have increased. We really have not seen any change in the american report of pain. Opioid use has increased dramatically as has the number of people who have developed opioid use disorder. Those intertwine in epidemics. My epidemiologist. Showinga map of london cases of cholera. Snow traced to the water pump. The solution was to take the handle off the pump. And it had a tremendous effect on the cholera epidemic. , as thethis slide kilograms of opioids went up, so due to opioid use disorder. This is the map of london from the opioid epidemic. It has been discussed to take the handle off the pump and reduce the number of prescriptions. The center for Disease Control and prevention have developed an evidencebased guideline in which they recognize that nonopioid therapy is preferred for chronic pain. Use the lowest effective dose for the shortest time and exercise caution and monitor closely. To create our own clinical practice guidelines, we have them for many medical conditions. The methodology which takes into theunt for domains and balance of desirable and undesirable outcomes and the confidence in the quality of the evidence as well as other factors. This evidence hierarchy might be familiar to you in the audience. Other guidelines were often based on expert opinions. For these guidelines, we looked to at least observational studies that show some control element. Clinical trials or even better metaanalyses. We came up with evidencebased recommendations to our practitioners. Exercise, tai chi, other nonpharmacological treatments. Nonopioids over opioids. Things like nonsteroidal antiinflammatory drugs, ibuprofen, and the like. , strongly,d against initiating long opioid therapy for chronic pain. And providing overdose education , making it widely available as possible. This has been an education for providers as well as some that we have disseminated across our system. We have key metrics and we have seen some improvements including a 33 reduction since 2012. The number of veterans receiving opioid therapy has been reduced by 39 . With communicating Prescription DrugMonitoring Programs in all but five of the states, which is a tremendous technical feat because not every straight Prescription DrugMonitoring Program uses the same software. And we dont necessarily communicate with each other or with us. But i have to give credit to my colleagues in Pharmacy Benefit Management for overcoming many hurdles. I wont go into much detail, but nationally, we have been making progress and Overdose Deaths have continued. This is a complicated picture that dr. Ciccone helped discern for us. Intertwined epidemics. For developing heroin addiction. Lets get back to my patients and nurse. When they said no more prescriptions, she turned to the illicit market. Now i explain to her the mechanism of action. Treatment for opioid use, it should be evidencebased. It should be lifesustaining. Empowering the patient to be empowered in their care and not a passive recipient. For patient centered care, it begins with shared decisionmaking. Is the expert on his or her life. Clinicians are experts on the entire menu of Treatment Options and we provide that information in a way that is easy to understand. My colleagues in the v. A. And the app at academic detailing service have created materials that make it easy to convey the rationale. Kind thatrticular goes with methadone. Througheen shown science to reduce hiv risky , andior, criminal behavior importantly, opioid abuse. And they also showed there are two kinds. Methadone is a full agonist and the view from morphine with a partial agonist. And makes it safer to prescribe for any setting. It is really only available opioid special certified treatment programs. And there is the full antagonist. I am able to provide this information. It is fda approved. It reduces mortality. Nd it is recommended we also discussed the extended release injectable that would block the opioid receptors and any opioids for pain. She elected not to take that one. Itanted to also mention that is not just the medication alone. The close monitoring by the clinician. The measuringbased tool, educating the patient about the opioid use disorder consequences and treatment, connecting the dots if you will. The groups in the community and making important lifestyle changes. My particular patient was attending a lot of groups and classes, so she was learning at a rapid pace. Because of the chronic pain, i suggested she split the dose and take it twice a day rather than once a day. And she completed our intensive outpatient program. And really within a week of starting this medication, she was so engaged. To a continuing care group, because of our system, i work in the intensive phase. That was the best medication. Telling me about another person that she knew back when that she encouraged to find treatment. She moved on and she keeps dropping and every once in a while to know how they are doing. It is often episodic as if we case ofating the pneumonia. And once we finish the 28 day inpatient intensive care program, we would be cared for the rest of our lives. But these are more chronic illnesses that would benefit most from the longview. Were taking the synthesis of the evidence and suggesting this model moving forward. We have good evidence that groups like Alcoholics Anonymous is helpful. And then disseminating out the evidencebased treatment into General Health care settings, theever the patients are, hepatitis clinics. Managing those most complex patients. But i like to point out on the graph. It is not just overdose mortality. What are our challenges and next debts of getting this lifesaving treatment to those who need it . The doctor alluded to this earlier. Hospitalized, only 17 received medication hospitalization. Can you imagine if we treated diabetes the same way . Percent received some Psychosocial Services following high hospitalization. 40 received no continuing care. The medication assisted treatment. We have a long way to go. And in the v. A. , patients that are clinically diagnosed with opioid use disorder, that is through outer systems. 34 received medication in fiscal year 2016. This will continue to increase. Challenges on are how to disseminate these evidencebased practices. It even asws is, demand has been increasing, the efforts we have made to providers and support them with consultation and education have increased what we are prescribing. And i would like to just present our evidencebased models we could be following. This is filing the colleagues work. It they randomize patients in primary care to receive physician management. This brief counseling i mentioned before. Either once a week, tapering to monthly for stable patients, or receiving an additional hour of counseling. All of the patients can receive that. They had some Pretty Amazing results. Most 80 retention in treatment at 12 weeks. And four to five weeks of continuous consecutive abstinence. That additional hour of Cognitive Behavioral Therapy that we know is helpful really didnt make a difference as long as the medication was prescribed with close monitoring and the brief counseling by the prescriber. That is an opportunity to disseminate this more widely. This is from the night of Clinical Trials network. It similarly disseminated out a model. To general Mental Health care settings. We found that while patients were engaged in treatment, their chances of remaining sober are 10 times greater than after it was tapered off at the end of the trial. And this is the socalled massachusetts model of nurse care management. By dan offered, colleen labelle, and other colleagues. They take this model and instead of the physician or the prescriber doing the grief counseling, trained nurse care. Anagers work with a counselor as well and they have been, through that model, to dramatically increase the number of patients receiving buprenorphine. Similar but different models in the state of mexico, it was heavy hit early on in the opioid crisis. The state of new mexico realized they needed to disseminate medication out to rural areas quickly. They developed a model using a telehealth hub. In which providers in primary care clinics in rural new mexico had a weekly meeting, basically clinical rounds like you might have done in medical school and residency, only done virtually using telehealth. Theyith that training, were able to dramatically increase the availability of medication assisted treatment. I will mention this one model from the alcohol literature. They minimize patients to receive alcohol care management. Again, with care managers. For treatment of alcohol use disorder, they found that primary care. Better engaged in treatment because they didnt have to pass from one clinic to the other . But there percent of heavy tonking days was superior those they got treatment as usual. We use the same techniques for pharmaceutical companies to promote evidencebased best practices. They helped partner with our overdose education. This is just a graph that, since 2014 when we started this, we have actually dispensed over 71,000. Point, 75,000. Potential next steps, there is a lot more than its to be done in terms of implementation science. We have actual treatments that work really well. They are wellestablished by the science. But getting them out to the patients that need them is the next challenge. They are also exciting and even better medications that i talked to us about. Education, right now, physicians have to take an eight hour training course. Nurse practitioners and physicians assistants have to take 24 hours of training. What about having that 24 hours of training in that basic. Urriculum we will learn from those and apply the Lessons Learned to continuously improve our process. Opioid use disorder is preventable. It is treatable. Effective treatment is patient centered and evidencebased. And we do need more help for newer and better treatment as well as how to implement the ones we have. Thank you. [applause] deborah dan and nora, would you come up . We will take questions from the audience. But you need to line up. There are microphones in the two isles. Two aisles. When i call on you, give your name, affiliation, status. Question. O ask a let me start with karen. Is there a difference between the veteran population and the nonveteran population . Men and women of the same age group in terms of their rate of taking drugs or using opioids . Drexler there is an increased risk for chronic pain. I dont know off the top of my head if we prescribed opioids more for those that have chronic pain. Makes sense that they have more chronic pain. They are very demanding. My son did that. Why is it that some people can have, for example, break a bone forave surgery and take it time. Others quit taking it. It is not just for opioids but for any drug. That some people get more addicted than others. If youways want to know can give me a test that will let me know if i will describe in opioid. We know a lot of that will be genetic. But we dont have the genetic test right now. There are many things we can one of them, have they been addicted in the past . Have a prior history of addiction. Alert physicians. Younger you are, the greater the risk that they may have that they will become addicted. Theyis one of the reasons will not be prescribed for teenagers. It is a factor that contributes to that. Mental illnesses can increase your risk for becoming addicted to drugs because it can make you feel better and it leads you to actually seek them out to medicate themselves. , there is of the day not a test that can guarantee you a patient is not going to become addicted. There are factors that tell you if someone is a greater risk. Just as it is describing the guidelines. Carefullyery describing that every time the prescription is going to be renewed, there is not any development or misuse of opioid or addiction. I wanted to refer to your graph that shows the heroin users on the left side. The younger users. Over . Ey just switching are they people that wouldve been cocaine addict or Something Else years ago . That it is the end drug or less expensive or Something Like that . People these are new that never wouldve become addicted to another substance . Complex and not epidemics can have increases theat size of the population. I retested it. What i would like to answer your question within and it note. In my observations, my team and i have been to low towns outside of boston. We see a lot of new people out there. They are not necessarily coming from prescription pills anymore. Sureare young and im not if they wouldve done another drug if heroin wasnt the thing now. I know there is a mixed picture right now. A 29yearold outside of charleston, west virginia. He works with the daily heroin habit. And there is this 10 Year High School reunion. A small town where everyone knows everyones business. Whos left, who has stayed, who has died. Half. I almost had to stop the interview because i had a very emotional response to that. Pills and heroin. Two were industrial accidents but mostly was pills and heroin. It was something very large out there happening right now. Lets take some questions, go ahead. I just wanted to add a dimension to dr. Drexlers excellent presentation that one of the things that we did in our policy on longterm opioid use was to prohibit the use of pain agreements or pain contracts. From an ethics perspective, we felt that they were unenforceable and adversarial. And instead, we substituted a robust informed consent process. Patients get education and a good conversation about the risk benefits and alternatives to longterm opioid use. The two questions i had were actually about integrated policy strategies. Surveys. Atisfaction i have heard from clinical providers that they feel pressured to prescribe all drugs. But in particular, in order for patients to get the satisfaction, they will be judged on that. Aboutcond was, what thirdparty Insurance Coverage for opioid use treatment . What can be done to encourage other players in the market to get onto this initiative . Dr. Drexler i will take the first one. Im not an expert in thirdparty payers. It having been in the v. A. Im on the steep end of the learning curve on unintended consequences of policies. It is a little like safety and efficacy trials and medication development. Phase two, safety and individuals. They see what happens at an aware of out in the real world. About one third of the adverse wents that we know about, learn about it after market. After the fda has approved it. The same thing happens with policy. They create policy based on the science of what seems like it will work. But when you roll it out in the real world, you dont know exactly was going to happen. It is very important we keep monitoring. Its good to see if the policies have the intended effect. And make course corrections as we need to. I want to answer the second question because i read a lot about the issue of opioid medications and their use for chronic pain management. And i get emails from physicians that are experts on pain. Not using opiates as a first line of defense, thats what they are saying. , theyoblem that we have cover for it. The paperwork that is required in order to justify these alternative treatments. Im not accepted by the insurances. As a result, physicians cant do the right thing because it is cheaper to prescribe in opioid medication. We need to do structure on changes. If someone is not going to reimburse the patient, they will not begin that intervention. That is an aspect that we need to be very aware of. They are treating that spark that actually facilitates prescription of opioids. It is very tough. I am wondering if there is any evidence now that opioid addiction of this sort is spreading in china itself . And might that lead the government to become more serious. I dont have any evidence for that. Veryw that stimulants are. Opular there is high level agreement. To restrict the number of sentinel and a number of its andins from being produced exported from china. Another personal opinion is fairly simple. Im not sure how one effectively oftrols the tiniest fraction an illicit production in a country with enormous industrial capacity. Regulations,s and how are they going to pull it off . But it is china. Maybe they will. I want that control to happen. I really do. But it hasnt worked very effectively for drugs like cocaine and heroin in countries that have a lot less pull in the world than china does now. I was in china last year and we were trying to create a new model for treatment of patients that have heroin. A have a very severe problem with heroin abuse, but they have been quite successful in implementing those clinics. But specifically, they are exactly like you on that question. Are they seeing the consequences of the synthetic opioids . So i met with the director of the cdc and i asked him, heavy started to see an increase in doses that maybe pointing out to the fact that you are lacing heroin with fentanyl . And he did not know about it. Issue is, i think that a very different country. They have abilities of implementing intervention in ways that are much faster. I do not know the extent to which there is an accurate knowledge of the problem. [inaudible] im with Pacific Northwest university. I get the value of research, both fundamental and clinical. As a medical educator, were doing our part to better educate a professional approach. But it is disheartening to hear statistics that show that 17 properly insured get the treatment. We start to look at rural populations and medical communities. Take that a step further. We are thinking about the demand for these opioids. Social bonding, for example. What is going on in our society . Who will address these more fundamental things that drive behaviorsdo certain in excess that harm them and also the community. Who is going to take responsibility for that . I will start. Part is we either have or will have a severe labor shortage in Substance Abuse treatment. There is simply not enough providers. They are not distributed in a way. Promoting medical education. Medical school to residency. It could also help the incentive programs. Loan repayment or other kinds of incentives. Forromote a Generation Health addiction medicine. It would be tremendously helpful. Couple of colleagues right now, looking at the deeper root issues of this. I agree with the line that we prescribingwe are that effect we are in and we need to turn that. That is what we have settled into. Multiple miasma going on. Multiple overlapping culpability is says something about the segment of american society. Disenfranchisement, a lack of future, lack of opportunity. Lack of hope. In appalachia up toward the midwest. It is much more complex. I am feeling a little sense of despair and hopelessness, too. Slide andck to that we did turn that epidemic around. This specific epidemic, we have the tools and the ideas. To haveto create a way those resources and get them to the areas that might be culturally shifting. Experiencehave the or the personnel to do it. We can use these creative approaches to get that. Epidemic a thing quick can address and turn around the larger fault zone problem. Not quite so sure about that. I would like to reiterate that. Ways, we need to end up in a very positive way. I actually look at it from the perspective and say that what is the challenge that we have that we are addressing the opioid epidemic. We know how to do it. We have a roadmap that if we implement, we will succeed. If someone were to tell me exactly how we address the problem, it will be the primer. I wouldnt even know how to start. We dont have treatment and we dont know how to properly prevented. Have a better understanding. We know how the epidemic generates. We know how to treat it. It does require a very integrated approach. Campaignery successful with other disorders. With how we have dramatically reduced it. We can do it. We have the wafer century it is putting 1 billion for the treatment of opioid disorders. We have never seen anything like that. They want to be sure that that ponding is for evidencebased treatments. We speak about quality care on cancer. And we need to demand that. Improving the quality of care for people suffering opioid abuse. There is already other addiction. This one, will take then that one. Then we will adjourn and go and enjoy our reception. Army a veteran u. S. Thanks for your time today. To hopefully short questions. One built upon what weve been talking about. Whether it is the Mining Industry or any industry that seems to have it has been degenerated in the past century for new jobs. Veterans also face a transition crisis when they come out. Im wondering, what are the programs now . I get messages as well. It seems to be there is a lack of communication with the overall transition is veterans go in and out of different Healthcare Systems to understand what are some of these risks. Specifically for other members of the panel. Of 2016, ittistics has a specific list of drugs for 2015, marijuana is 2. 6 million. Pain relievers in general are 2. 1 million. Cocaine is 968,000. Lsd is 664,000. And methamphetamine is 225,000. To your last slide about separating out the heroine problem from overall pain relievers. It appears that heroin is quite low on the scale. And it might be doing this a disservice. Can i take the first second question first . I would just ask you to please google the department of the v. A. Huge organization and we have a transition care program. It veterans that are leaving can engage in health care with us. We also have programs for education and for employment. So please, reach out to us. [inaudible] ok. Thanks for bringing up the piece of ahis is one larger issue about american society. Marijuana is very common. It is not deadly. It just happens to be deadlier. Han the more common drugs remind ourselves that one of the legal drugs that is deadliest is alcohol. We have to constantly remind ourselves that we are working with teens and vulnerable beulations for what might light level of alcohol use, recreational use, the social use. People are testing their genetics. Alcoholism is highly genetic. People should know their family histories and magnify resilience. Actors to not progress i will emphasize a heroine. We are in the death grip of losing segments of the. Eneration and speaking of suicide is a major Public Health crisis right , it can be treated by treatment. What dont know exactly these numbers are. 33,000 deaths. It is possible. I dont think it would be completely off the mark that 15 of them are related to suicide. The loss in years in terms of the life expectancy. It is related not just of the overdose but to a significant increase we are seeing in suicide. The suicide was much higher. Strong linka very between both of them. And one of the things that the cdc guides will tell you, among the factors that are associated the higher risk is having a history of depression. Your reach for suicide. They were distinguished from the other. Deborah i actually do think it is one of the most topical and large size and the of the audience can attest to that. It before we go off to the reception, i would like to take one more chance to thank the Dana Foundation for all theyve done. [applause] and also to thank our terrific speakers. [applause] thank you. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2017] day on twitter. President trump tweeting a couple times today about the reaction to his firing of fbi director james comey. This afternoon, the president sent this message. Most of the questions at todays Briefing Center the round the firing of james comey. This is half an hour