i'm charles dunlap, the director for the center for science policy and society programs. the lecture this afternoon on the opioid epidemic is the second in 2017 foundation series on science in the society. the first lecture this year on the brain and video games was held in march and the third in september will be on meditation so please keep an eye out for the announcement date. the foundation is a philanthropic organization that supports brain research programs, publications and educational programs like this one. for the last five years, we've partnered with the foundation to present an annual lecture series on society and by my count this as the lecture in a series. we are grateful for the dana foundation support of the series and for the leadership in the series and our scientific responsibility human rights and law program. >> thank you. welcome. it seems to me hardly a day goes by there isn't a story i see either in a newspaper or o the n the evening news about the opioid crisis. and as i was thinking about that today, sure enough on the front page of the "washington post" is a story abouhas a story about he governors of maryland and virginia along with washington, d.c. as mayor are getting together to form a combined database to keep an eye on prescriptions and getting the drugs so it's just another day. a few days somebody sent me something that said that. the opioid painkillers, 92 million sees a lot of that. i wanted to kno want you to knoa reception planned. so tonight we are going to look at and eagle's eye view of the opioid epidemic and close in view from the institute of drug abuse to talk about possible treatment but the first speaker is a professor from the university of california san francisco specializes in community medicine and treating diseases. he was a leader in the hiv aids epidemic so he's going to talk with us tonight at the scope of the problem. >> there is no mouse function is there? >> there we go. i can't even begin to talk until my slides are up. hello, everyone. my perspective is one of trying to see ways towards increasing community health. doctor drug academic affairs at him and sent him off to -- heroine and fentanyl. i'm going to go through the epidemiological data comparing prescription pills with heroin with the epidemic curves and spend time talking about the manufactured fenc fentanyl. this is publicly available data. a little bit will come from my study from the national institute of health and drug abuse. for the first time since 93 the death rate has gone up year over year. here we have the two big elephant in the room that cancel each other out. but if we go to number four, unintentional injuries we see a bump up in 2014 to 2015. weaver shot in 2011 to find out that two of the leading causes have crossed over with drug poisoning on the rise in motor vehicle accidents on the decline but this is good news and bad news in the drug epidemic. the number of deaths now have exceeded car accidents, gun violence and even hiv you can see here i apologize it is a steep rise up around 1993 and then a decline. we moved the epidemic to a crisis. looking at hospitalization data this is the curve for the opioid epidemic. a dramatic rise in the 93 to about 2011 and some good news plateauing the proxy of the decline post 2011. this is based on the work that we are doing to restrict the practices. this is now an overdose on the dramatic increase up, just since 2008. the magnitude in this slide with a steep curve of concern year-over-year no end in sight. there's evidence that the number of users is rising coming from two paths. one is coming from opioid dependency finding heroine is not available and cheaper replacing the high level with a harrowing dependency and others are coming straight away now. the last few years with the availability has gone up. in vermont it's not supposed to happen but they do. it is transitioning they used the term as early as 2012. one group would transition back and forth because they are treated equally. we also wrote a story about those that transition with all of the new and young users telling a story about how they started with pills and then moved over. there is some data on the group looking at comparing the demographics by age. the pay overdose problem is 2012 to 2014 data 50 to 64-year-olds. it's no reason you want to show evidence for drug epidemic it is among younger people, there we have it. if we shift this over we see that transitioning of the overdose from year to year it goes down and you see from the bluetooth green is going up in that same 2012 to 2014. in the geographic region we see a difference. the opioid overdose is relatively even over a long time. how. we like to think that it's worse in places like appalachia. there are differences in the use curves but to the eye they look west by region and that isn't true for heroine. they've had a problem that is highlighted with the gold aero from low levels to high levels of overdose with disparity that cannot be explained by the population at risk. so in addition to that story, we have to tell another. let's talk about fentanyl. you don't go to a separate corner down the street and ask for a funny street name for this new drug called fentanyl. the heroine that you get if you were in that town in massachusetts for example coming you are going to get fentanyl contaminated heroine and the other is 100 times powerful as morphine by weight calculation. we've had multiple waves of this in the past but the latest is much longer than the other waves and it began in the late 2013. it is philosophically manufactured fentanyl according to the dea. it is a booster of campaign considered a side event and it is now ubiquitous in the cocaine supply and this implies that there may be a future for it as a new heroine moving forward. in addition to the main chemical, there is at least two dozen synthetics. the one we are worried about, there's a couple now it was the big 13 or four times as strong not meant for human consumption. it's a large animal pain reliever. so if an elephant is a problem that's what you need. the dea and its reports will tell u us a list of the manufactured fentanyl is coming from china and north america, not the contaminated pills but for the heroine is through mexico and coming up through the cartel distribution. and where is it going? places that have the most high fentanyl supply according to the national forensics lab in the drug and seizure data and rates of opioid deaths down to appalachia and new england. the same states that have a higher heroine overdose death. one slide on one reason why we got here. it's promoted as pharmaceuticals they were quickly adopted because they worked and they did what people wanted them to do but they also became problem drugs so they are technologically advanced in terms of the hypodermic needle and has caused us to the first wave of the opioid epidemic in the united states. to misuse and abuse over the generations some of which have been cultural and related to news sources, so the vietnam era heroin epidemic is devastating. it's coming from southeast asia. the colombian heroine wave which people don't know about came when the colombian drug cartels brought an entirely new product, they brought heroine in 1992 to the problematic drug use in the united states. now we have the opioid pill problem. think about the extended release capsules that have high doses of powerful opioids but they are dissolvable and injectable. it's coming in now in the late 2000 blank. talking about asking questions about it if mexico was producing a highly potent powdered hair when that's never been seen before and we don't know much about it. it's also coming in around 2013 a new source and technological advancement in that it is highly potent and it acts as a booster for heroine. there's other consequences besides overdosing this opioid crisis injecting drugs infectious disease risk, blood-borne virus, hepatitis c and hiv and we should be mindful that the severe outbreak in indiana there are many scott county counties in the united states. we also have to be concerned about the bacterial infection. because they love suffering and cost us a lot of money. all these things are preventab preventable. part of my research is asked to talto talkwith users. these numbers hide the pain, experience and resilience and coping that's going on among the population. we meet with users in the street. we watched the watch them as the their drugs and inject. all the while fascinated by the new chemicals that come in new forms, colors, powders, forms of covers, new solutions. when i first saw this it freaked me out i'd never seen it before and i've been studying this for 17 years. if it is freaking me out imagine what the users are going through trying to adapt to this new thing that's out there. they want our help and it's up to us to provide it. in summary, i'm proposing we start to separate them. it's not just one intertwined opioid epidemic that we need to treat heroine and fentanyl differently. it doesn't mean we are going to put the genie back in the bottle and it's the only answer. this is a epidemic of crisis proportions and it is at its worst unfortunately but it's also a crisis of economic opportunity. we turned the hiv epidemic around with a dramatic drop down. this is the effect of the appropriate government cultural social intervention treatment and prevention. it works it will work for the heroine and fentanyl epidemic as well. we shouldn't treated with the same anymore controlling prescription pill practices we can do. we need to treat heroine and fentanyl differently. we need to treat it as a poison epidemic. we are treating it as a drug epidemic and counting the dead bodies as they lie. we are not testing the drug accurately and informing the public accurately and we will talk more about that and the question and answer period. we need more in the treatment. we need more of this for the recovery acted as good a wonderful bipartisan response. it isn't going to be enough there is no way. we need faster responses to overdose. he needs to be not just in the hands of the paramedics and police that we need to give it to peers and it needs to be this generations at the epipen. it can bridge people as a treatment for aiding and abetting drug users in the political sphere. thank you all for your kind attention. carmack. [applause] that was a good introduction for next talk which will be coming from the government and i'm interested to hear how much the government is doing. our speaker is the director of the nation institute which is one of the main institutes of health. she's a true near and theology, the pharmacology of substance abuse and will tell us what those drugs are and what her office is doing. >> good evening, everybody. please be seated. last time, we were discussing the issue of marijuana and how the change in policy will affect the function of marijuana. they were speaking about the worst crisis ever seen in the united states that relates to. what's interesting about these which is very public. number one, for small, the epidemics that we have in the past. this one basically came out of the healthcare system. it came out with good intentions which were need to treat those patients that are suffering from pain. it's particularly recognized that there was a concern that this was not properly treated for their pain. since the late '90s, in the beginning of 2000's, it was decided that these would be the area of pain treatment and among the many for the joint federation commission of the hospital's and they recognized pain as a fifth vital sign into treated. coupled with a strong apathy and the need to treat patients, at the same time they were. [inaudible] that resolved it in the prescription of what we avoid prescriptions. in the past there has been a lot of fear about the use of opioid for pain. they didn't want patients become addicted. that shifted radically in the 2000 with very strong advertisement from the pharmaceutical industry so that they would prescribe opioids. if you have pain you will not become addicts because of your pain medication. we came basically, confounded about what we have learned that we are faced, he knew these drugs were not addictive. unfortunately, the numbers doctors are prescribing more and more opioids and that is not the case. as you look at the numbers -- forward, you want to look backwards. in 2009, 2003, one of the things they were showing me was the monitoring of the future. monitoring the future is you know with teenagers. what struck my attention was in 2003 was the rate of use of prescription opioids like vicodin was 5% of teenagers. i have never ever seen -- and i'm not a psychiatrist but i've never seen so many teenagers taking in what we write. then i looked at the numbers and we started to realize that there were some massive abuse of prescription through all the ages. it's almost like people were not listening to us and what were saying. we found a problem with the prescription opioid. they felt they were safe. at the same time there were reactions that you don't want to joke about the proper treatment of patients with pain. it wasn't until we started to see numbers like this one that the agencies realized, my god, we have a serious problem in our hands. these numbers are growing abruptly and rapidly. the overdose rates from the cdc and in 1999 they were pockets of the united states were very high overdose. in particular, you can see the different regions. fourteen or 15 years over the united states has become affected. you can still see the main area in the appellation region. by the prior region you can see new mexico. i'm waiting for the day because actually for starting to see further expansion into the northeast. [inaudible] so, why is it that opioid constrictions prescriptions and overdoses result in death? this is the peak. underneath, there are multiple others things associated with opioid abuse. there are a wide variety of them they have psychological effects. the preceptors that are in our brain and all in our body and these receptors associated -- and this is something that showf corridors showing the highest levels and the full scale showing the lower levels where they are located in our brains. as you can see, there is a very high concentration and all of the regions of the brain that are engaged in our ability to perceive pain. that includes the. [inaudible] this is fundamental for our ability to perceive pain. so your receptors that are in an area that allows us to involve an emotional processing and if these fundamental for the negative reaction that we get with pain. that area is also loaded with opioid medication. when opioid medication binds to receptors it inhibits the preceptors of pain. this is the reason why opioid medication are the most effective medication that you can have for addressing severe, acute pain. it is almost immediate. the issue was that the acute, severe pain is something that you may, actually, may save your life through these drugs -- i have been in a car accident and i want them to, they would want to think because of the pain been so intense and it was extraordinary how the opioid i gave them healed it. the was gone and that sense of euphoria and relaxation was there. that's exactly why these drugs are problematic. they are not just located in these pain sensors they are actually located in that area over there. these region is one of the most important region in professing pressure. when the receptors bind to the regions, they bind to the sensor and opioid medication can be one of the most rewarding and most addictive. we also have opioid receptors located in the brainstem which is the lower part of the brain in the back. that's where we have many of the nuclear that is involved with these functions. one of these nuclei is associated with responsible for our breathing. when opioid medications bind to the sensors, they inhibit breathing and that's why you can actually ultimately died from an overdose because you stop breathing. this affects the reason why opioid medications are far from being ideal as treatment, not in one instance for pain, but the problem emerges when they use it for the management of chronic pain. according to the when you have pain that lasts for three months so what is the problem with opioid medication for chronic pain? there effective when you give it acutely. your body will rapidly come tolerant to it which means that you need higher doses in order to achieve the same level of for the higher the dose you go, the higher the likelihood that you become addicted. so, the effects of the drug wile repeatedly, leads to conditioned response that leads you to crave that drug and it does that on all levels that can lead to addiction. also, because the tolerance to the effect of opioid in the brain. [inaudible] the rate of the opioid reading sensor which accounts for why these medications are far from ideal for the treatment of chronic pain because you are going to need higher and higher doses and the higher the dose, the greater reason for addiction and the greater risk of overdosing from too much. as i pointed out, the epidemic started from our over prescription. there's actually into a 13 something like 235 million prescriptions in the united states. that's provides one month supply of opioid medication for every. [inaudible] in the united states. you say, maybe the united states , is also suffering from severe pain. if you look at the statistics, it is estimated that among elderly americans, 30% of them suffer from chronic pain. that in no way justifies this massive prescription. in fact, the united states actually prescribed between 80 and 85% of all opioid medication in the world. these leads us to prescribe that it's overprescribing. this facilitated the reversal of this medication and it got to the black market and now it's been abuse. we generated prescription addiction to opioids. people who were given medication for pain by the doctor become addicted and then those that actually started to experiment with his drug because of the rewarding effect. these two are ultimately generates a similar syndrome of addiction. there was a massive amount where were trying to train physicians and proper prescription of a. mick medication because when. [inaudible] physicians were starting to prescribe with no knowledge so now we know for example, that they are particularly risky for overdose. when you give more than 80 milligrams equivalent, when you mix these medications other medications that affect your breathing, or when you mix them with alcohol, were still continuing to do these prescriptions. risking overdoses. were seen changes in the right direction. 15% decreasing in the amount of opioid being prescribed between 2010 and 15. this is in the right direction. unfortunately, this is not in any way change the overdose rates that have continued to escalate very much in line from what was in the prior presentation. here you have 33000 people die from an opioid overdose. when you see the commonly prescribed opioids you are seen they are not going down. what is going up is the line of other synthetic opioids. [inaudible] what is driving these high rates of overdoses? for many many years we have low levels of abuse in the rate of death was it was constant, 2000 people dying every year from overdose. then the amount starts to go up. it wasn't dramatic, it's actually around 700, 800,000 coming from 500,000 and the number of people have basically quadrupled. what is driving this is mark we have a much purer heroine. [inaudible] in the meantime, were seen that these here and all is heroine is being laced with fentanyl. that's what's driving the massive amount of overdose. abusers, 80% of them, start with prescription rates. if you analyze what happens from the heroin use in mexico actually started in spain where there actually the largest problems with prescription opioid. it was cheaper and easier to go to heroine from opioid. 80% of the new cases are emerging from those who became addicted to prescription opioid. what you don't want to communicate is that we want to contain the heroin epidemic which would make prescription opioid available because it's leading people to change because it's hard to get it. that's exactly the incorrect answer. in order to address this we have to prevent abuse and addiction to description opioid. it would prevent those transitioning to heroine. these are the numbers in terms of how when a drug becomes an important role. were getting heroin from mexico and that's coming with an extremely high pure rate and decreasing increasing dramatically. the united states -- in the meantime, fentanyl has been easy to synthesize. what you need to know about fentanyl is that it's coming from china and so often these synthetic, you can bring it in small volumes. so from a supply effective you can it's a tremendous amount of challenge. you're not calling carrying a big volumes. yet the small amounts that are have a multiplicity of doses. the challenge is not from the supply perspective only but this is a tremendous problem from the public health consequences associated with the overdose. so, what does the nih are doing to address this problem of the epidemic our perspective is when we have the hiv epidemic, or the ebola epidemic, we address it using scientific signs. it is not different for the opioid crisis. the way we we need to understand the root cause of the problem. that we have a problem with patients suffering from pain but which we don't have many alternatives. in particular, it's for the management of chronic pain. it is estimated that in the united states a hundred million people suffer from pain, moderate to severe. that's one area. we need to file a better treatment for the management of chronic pain. the other one is we need to do interventions that actually can prevent the overdoses. we now need to actually design alternative strategies that will help us. otherwise, bill overdose again. finally, we need to more treatments for opioid addiction. [inaudible] those are very useful but it is not sufficient and also you. in the area of pain, you say, here we have an incredible opportunity, a hundred million people that are suffering from pain and yet we don't have many medications. for many, many years, physicians poured millions of dollars to develop an opioid medication that would not be addictive. these were, this resulted in similar results. after all, what many of the pharmaceuticals did was actually , pride themselves from the pain, development of pain medication. now science has recently with the ability to look and identify the three-dimensional structure of the receptors been able to identify the receptors to various. [inaudible] they also activate. [inaudible] they are now trying to develop medications that do not engage the receptors with the notion that they will be useful for pain management without with the overdoses or without producing addiction. research is underway, clinical trials are being done in one of those. [inaudible] for overdoses, we work with the more widely available for a wildly success. [inaudible] they say it's almost impossible to resuscitate them because they die as they are injecting the drug. fentanyl and this other is getting to the brain so rapidly. patients that are resuscitated, they overdose again and eventually die. we need to develop interventions that will help these individuals that overdose with treatment so they do not actually this mexican protect them from future overdoses. finally, medication. if we have three modifications,. [inaudible] and each of them is different. depending on what characteristics, you can use one or the other and they should help prevent relapses, overdoses , but they are not being used. actually, 50% of individuals in the united states would benefit from a medication and getting it multiple reasons but there is a lack of infrastructure. [inaudible] developing medications, alternative medications that will be in clients with the partnership that we need with the pharmaceuticals that the medication district this would facilitate compliance of the patients of this opioid medications. finally, science will look at transformation some areas that we have been exploring not just for heroine but for other fentanyl as well. the development of vaccines. vaccines, using the same strategy that we use for other vaccines that would generate antibodies so that when the person takes the drug the antibodies find it and interferes with the sequencing to the brain. not this would be useful for not preventing overdoses alone but helping for the future. i would like to this the documents. [inaudible] i want to thank you for your attention. come back. [applause] thank you. this has not been a real cheerful session. i know that a lot of you are interested and this is a high attendance. i'm hoping our next speaker gives us a little cause to walk out of here with a little bit of hope. our speaker is karen. she is the national mental health program director for addictive disorders and veterans administration and to know more about misuse and drugs than the veterans administration. doctor drexler is certified both psychiatry and in addiction and she will talk to us about treatments. >> thank you so much i am honored to be here. thank you to aaa s and the dana foundation for this invitation. i am delighted to give you a third perspective tonight. i am, as deborah said, an addition psychiatrist by practice at the va medical center where i practice for most of the last five years. i also for the last three years, though, have been working for ba draws the office here in washington dc doing addiction treatment policy and having the opportunity to be a consumer of compliance on two levels, both as an individual practitioner but also as someone who's trying to translate the science to improve the healthcare of a relation. i am employed full-time by the veterans affairs and i have no commercial conflicts of interest . tonight, what i'd like to do is talk about i don't have to talk about opioid use dessert disorder because it has been done so well tonight and i'll mention that she talked about opioid treatment begins with prevention and how he used the science to inform our policies about that. also, how effective opioid used his treatment from the side of the art of medicine, how we apply with the science and shown us in a way that patient centered and collaborative when we are working at our best. i'd like to share a case example this is a patient of mine, ten years ago. i share her story different she is a veteran but because this could be any one of us. she was very hard-working, licensed professional nurse, practical nurse who was referred for substance abuse treatment after an overdose. this is really the combination of 30 years of experience with prescription rights and other controlled substances. she injured her back at each 24 and was treated briefly with some pain medication. she had a series of re- injuries and surgeries and ultimately ended up being treated with both opioid and muscle relaxants. as her increased, her drug hunger became greater and even by shopping for multiple providers it was not enough. she ended up buying some pills on the street and ended up with an overdose. now, for her, she met the criteria for prescription opioid disorder if she is taking prescription opioids we don't include the increasing tolerance or the withdrawal as criteria for making a disorder diagnosis. she really had most of the symptoms. she had craving or strong desire to use opioids. she was using in situations when it was hazardous, when she was too intoxicated to drive. she was using larger amounts and then she intended and had difficulty cutting down. spending a lot of her time figuring out how to get her next dose of opioid and continue to use despite knowing that opioid was causing major problems. in fact, after the overdose, mary care provider said i will not prescribe opioid for you unless you go to the substance abuse treatment program. that's when she saw me. i was the gatekeeper for her next prescription of opioid that she was hoping to obtain. as, both previous speakers have talked about, since the 1990s, prescriptions have increased and we have really not seen any change in americans reports of pain. however, the overdose does have increased dramatically and as has the number of people who have developed the use disorder. those are intertwining epidemics this is just my slide. if those of you are epidemiologists may recognize this is a map of london in the 1800s and saying cases of cholera that doctor john snow chase to the broad street water pump. the solution was to take the handle off the pump and it had a tremendous effect on the cholera epidemic. i think, this slide that we've already seen some versions of this where as the kilograms of opioids sold went up so did the deaths due to opioid overdose in the admissions for overjoyed use disorder. this is our map of london for the opioid epidemic. one important intervention, as already discussed, is to take the handle off the pump into reduce the number of prescriptions for opioid pain medication. so, the centers for disease control and prevention has developed an evidence-based guideline in which they recognize that non- opioid therapy is preferred for chronic pain for the reasons we've already mentioned. were using opioid for the lower dose for the shortest time. we need to exercise caution and monitor closely. in the department of veterans affairs we department with the department of defense to create our own clinical practice guidelines and we have them for many medical conditions. we use the cdc grade methodology which takes into account, including the balance of desirable and undesirable outcomes that are competence in the outcome of the evidence as well as other factors. we use this evidence hierarchy that may be familiar to many of you in the audience. whereas, earlier guidelines were often based on expert opinion, these guidelines look to at least observation studies that show some control element and the best of all, randomized clinical trials or even better meta- analyses and clinical trials. based on these, we came up with 18 evidence-based recommendations to our practitioners. i'm highlighting four of them here. we recommend alternatives to a great therapy, such as self management strategies, exercise, tai chi, other non- pharmacological treatments and when they are used, non- opioid over opioids. like ibuprofen and the like. we recommend against, strongly, initiating long-term opioid therapy for chronic pain. we recommend for patients that are receiving opioid therapy, ongoing risk mitigation. things like, monitoring urine drug testing, state prescription monitoring program to make sure were not double prescribing, monitoring for overdose potential and providing overdose education to our patients, prescribing and making as widely as possible. finally, as did the cdc, we recommend monitoring patients who have chronic pain for the development of the abuse disorder and when we find it, providing medicaid medication. in order to take the handle off of the pump, we have been reducing opioid prescribing to our opioid safety initiative and this is been in education for providers as well as some metrics for quality improvement that we have disseminated throughout our system. we have some key metrics and we have some improvement in opioid prescribing. 33% reduction since 2012 and opioids over time. these are numbers of veterans receiving. the veterans on long-term opioid therapy with a urine drug screen has increased to 87%. we are communicating with prescription drug monitoring programs and all but five of the states which is a tremendous technical feet because not every state prescription drug monitoring program uses the same software and they don't necessarily communicate with each other or with us. i have to give credit to my colleagues in a pharmacy benefits management for overcoming many hurdles to get to this point. we've already seen the slides before so i won't go into much detail but the va is not alone. nationally we have been making progress and yet, overdose does continue and this is a complicated picture that the doctor helped to discern for us of these intertwined epidemics. as was pointed out, patients who are prescribed opioid long-term are at greatly increased risk for developing heroin addiction. let's flip back to my patient, the nurse. but her physician told her, no more prescriptions she turned to the illicit market and when she came to me for treatment, i talked with her about. [inaudible] i explained to her the mechanism of action and took the approach that we were advocating systemwide. treatments, just like should be patient centered, evidence-based and life-sustaining and empowering the patient to be a partner in their care, not a passive recipient of care. it also needs to be accessible to those who need it. for patient centered care, it begins with shared decision-making. the patient is the expert on his or her life and hopefully, clinicians are experts on the entire menu of treatment options and we provide that information in a way that's easy to understand. my colleagues in the va and our academic detailing service created some education materials that make it easy to convey the rationale for our medication treatment. opioid therapy is a particular kind that includes both. [inaudible] it has been shown through science to reduce hiv risk behavior, clinical behavior and opioid use. as she also showed earlier, there are two kinds, methadone is a. [inaudible] they have a unique method of action that makes it safer to prescribe in any settling methadone because it has properties and is only available to special certified opioid treatment programs. there is a full antagonist. i am able to provide information , you don't have to go to a special clinic every day to pick up your medicine and take it in the clinic. it is fda approved, it improves treatment retention, reduces mortality and is recommended for most patients except for those who have anticipated need for opioid pain medication. i talked to my patient about how the patient sign that helps improve their pain. we discussed one other option with the extendable release which blocks the opioid receptors and any other opioid pain. she elected not to take that one i wanted to also mention that it's not just the medication alone but also medical management and there are several research studies showing this approach that relatively brief causing but close monitoring by the clinician, including drug testing, asking the patient about their use, asking about consequences and potentially using a measurement -based tool like a monitor. my particular patient was also attending a lot of groups and classes learning at a rapid pace , different skills to support her. she elected to take. [inaudible] because of her pain, chronic pain, i suggested that she put the dose and take it today rather than once a day. she completed our intensive outpatient program but within a week of starting the medication she was so engaged in learning so much that started exercise, started being active in a recovery group and then i transferred her to a continuing care group because of our system , i work in the intensive faith she had graduated and move on to a less intensive face but she kept me back at every opportunity to stop by my office and they, doctor drexler, that was the best medication, i can't tell you. telling me about another person that she knew back when that she saw and encouraged to combine treatment. it really turned her life around she remained in recovery and medication for years. as she said, she moved on instantly stopping in every once in a while to let me know how she's doing. i wanted to raise this issue, that we are treatment first, since these disorders are often episodic as if you were treating a case of pneumonia. once we finished the 28 day inpatient intensive program, we would be cared for the rest of our life. these are really more chronic illnesses that would benefit most from the long views, from the chronic disease management model. this is something that were taking the emphasis of the evidence in suggesting that the model moving forward and this is a work in progress. we haven't implemented it yet. we are promoting self-management , we have good evidence that dissipating in group mutual health like narcotic anonymous is helpful. teaching coping skills that folks can use to cope with pain or to help to sleep without using medication. then, disseminating out evidence-based treatment into general healthcare settings wherever the patients are presenting. and taste clinics, and pain medicine, and also, keeping infrastructure and specialty care for managing those most complex patients. at this part, i apologize, you can't see the graph i'd like to put out on the graph is that the medication assisted treatment with methadone and. [inaudible] reduced mentality mortality and it's not just overdose mortality in all cause mortality. what are our challenges and next steps of getting this life-saving treatment to those who need it for smart among this practice was alluded earlier but among private insured, 70% received medication following their hospitalization. can you imagine if we treated diabetes the same way? 54% received psychosocial following application but 40% received no continuing care. according to the data stats 13, 27% of treatment plans for heroin use disorder in the clinics included medication treatment. have a long way to go. in the va, patients who are clinically diagnosed with opioid use to serve her, through our system, wherever they present, 34% received medication in fiscal year 2016. can anticipate the demand for opioid and it will continue to increase. our next steps are challenges on how to disseminate these evidence-based practices widely so they are available. as i mentioned, the good news is , even as a man has been increasing the efforts that we have made to educate providers and to support them consultation and education increase are prescribing and i'd like to present to you for evidence-based models that we might follow. one is a brief counseling is sufficient for many opioid disorders. they randomize patients in primary care to receive position management, grief counseling that i mentioned before, either once a week, or monthly for stable patients or with an additional hour of counseling or if the patient received. [inaudible] they had the amazing results. almost 80% retention, in treatment at 12 weeks and four to five weeks of continued, abstinence. that extra hour of therapy didn't really help as long as well as long as the prescription was monitored and the prescriber was helpful. this is from the clinic trials network, similarly, decimated a very similar model to general mental health care settings. what they found was that while patients were engaged, their chances of remaining sober for ten times greater than after the [inaudible] was tapered off at the end of the trial. this is the map, massachusetts model of nurse care management by dan alfred, and other colleagues. they've taken the filing model and instead of the division or prescriber doing the brief counseling, trained nurse care managers to the brief counseling in the follow-up. they work with any team with a clinical pharmacist and counselors as well. they have been able to, through that model, dramatically increase the number of patients receiving. [inaudible] then another but similar different model in the state of new mexico, as you saw was heavy hit early on in the opioid crisis, they realized they needed to disseminated out arrows and they developed a model using a telehealth hub in which providers and primary care clinics in rural new mexico had weekly meetings on basically clinical rounds on you might have done in medical school and residency, only done using virtually telehealth. with that training they were able to dramatically increase the availability of medication treatment. finally, i'll mention this one model that's from the alcohol literature. they randomize patients to receive alcohol care management, again with care manager supporting the primary care doctors, and the prescribed naltrexone for treatment of alcohol use disorder and they found that those two were randomized that it helps not only with with a better engaged with treatment they didn't have to pass from one clinic to the other but the% of heavy drinking days was also superior to those who got treatment as usual. i'm very hopeful that will be able to meet these models out and one key, at least for us in the va, is academic detailing in which we use the same techniques the pharmaceutical companies used to promote new products, to vote evidence-based practices. they help to partner with our overdose education and lock. distribution and this is just a graph 14 when we started this we have actually dispensed over 71000, at this .75000, rescue kits. potential next steps are a lot more to be done in science. he had some actual treatments that work pretty well and are well established by the science but getting them out to the patients who need them is the next challenge. there are also new exciting, better medications on the horizon that talks about earlier how can enhance education. right now, in order to be prescribed. [inaudible] sessions have to take an eight hour training course. nurse practitioners and pas, since, after take 24 hours of training. that seems like a burden for someone with a busy clinical practice but why is anyone graduating from medical school or nurse practitioner or pa school without having a eight or 24 hours of training in their basic curriculum that's one area where we can improve. we could also let folks in the field try some of these models for lamenting like nurse care manager like the go telehealth hub and learn from those and apply the lessons learned to continuously improve our processing. so, opioid use disorder is preventable and treatable, effective treatment is patient centered and evidence-based and we do need more help for newer, better treatments as well as how to implement the ones. thank you come back on. come back come back on. we will take audience questions. you need to line up your microphones in the two aisles and when i call on you, please give your name and affiliation status. i wanted to ask a question. let me start karen. if the veteran population and the nonveteran population, in terms of their rate of taking drugs. >> so, there is an increased risk on pain for veterans and i don't know off the top of my head whether we prescribed opioids more for patients who have chronic pain rather than the general population. >> it would make sense that the veterans have more chronic pain. they've had more mac rigorous jobs yes to manny. why is it that some people can have, break a bone or have surgery prescribed in opioid and take it for a period of time and some people become addicted and other people just taking it to mark pack we are all built differently. one of the things you come to recognize for any drug is that some people are more addicted than others. what of course physicians want to know is can you give me a test to let me know if i'm going to prescribe them on. are they going to be a higher risk or not. we know that a lot of the ability is genetic but we don't have the genetic test right now that can help us but the many things that we can actually ask patients that can give us an idea of the risk. one of them has to do with have you used drugs in the past. this should alert physicians about the ability of high risk. also, do you know that the younger you are the greater the risk you have at becoming addicted. this is one of the reasons why in general medications cannot be prescribed to teenagers unless they are necessary. family history is also a factor that contributes to that. mental illnesses, they actually in many instances can make you feel better and that leads to you seeking them out medicating themselves. at the end of the day, there is not a test that can guarantee a patient will become addicted. there are risk factors that tell you if someone will become a greater risk. if someone will be prescribing the opioid repeatedly, within the cdc guidelines, they must be monitored carefully and that every time a prescription will be in use the physician will evaluate to make sure there's not any misuse or addiction. >> thank you. dan yes i wanted to refer to your graph that shows the heroin users as being younger users. they are switching from cocaine addicts or something like that, years ago. heroin is the in drug or something like that. or are they attracting new people who never would become addicted to another substance? >> yes, it's complex and not completely known but we are in this wave effect. epidemics can have this sort of way the fact that in people and increases the population. we tested the size of the vulnerable population by excessively prescribing opioids. what i'd like to answer your question is an anecdote. so, in my observations my team and i have been two towns outside of boston, baltimore, chicago, west virginia, to see a lot of new people out there and these people aren't necessarily coming from prescription pills anymore. there's a new wave that is coming in. there they are young and i'm not sure what they would've done another drug if heroin wasn't the thing now but i do know that there's a mixed picture right now. there's also a cultural wave of the anecdote, for example, 29 -year-old in a small town outside of charleston, west virginia, nice guy, works, has a daily heroin addict. everyone knows everyone's business, everyone knows who's lived, died, half high school classes gone. the first time in 17 years i almost had a stopped interview because i had an emotional response. there's usually one or two motor vehicle accidents but there's the large out there. then there's no easy answer. >> let's take some questions. go ahead. >> my name is sp. i'm the chief policy of the veterans administration i wanted to add a dimension to doctor drexler's export excellent presentation. one of the things we did in our policy on long-term joy to do so was to prohibit the use of pain agreements or pain contracts because from an ethics perspective we felt they were unenforceable and adversarial and instead be substituted a robust informed consent hotline. patients could get education in a good conversation about the risks, benefits and alternatives to long-term opioid use. the two questions i had are about integrated policy strategy patient satisfaction surveys, i've heard from clinical providers outside the va say they are pressured to prescribe all drugs but in particular, opioids in order for patients to give them a positive satisfaction rating because will be judged on that second, what about third-party insurance coverage for opioid use treatment and what can be done to encourage other players in the market to get onto this initiative? >> doctor drexler, will you take that smart. >> i'm not an expert in third party, so i can take the first one. i am on the steep end of the learning curve of unintended consequences of policy. my thought about it is that it's a little like efficacy trials and medication development. you do phase one, state the healthy individual. phase two is safety in individuals affected and stage three is the clinical trials and if they are positive and encouraging then you roll it out and monitor to see what happens out in the real work. i read a paper just this past week that about a third of the events that we know about, we learn about aftermarket. after the fda has approved. same thing happened policy. we do our best, as you saw, to create policies based on the science of what seems like it will work but when you roll it out into the real world you don't exactly know what's going to happen. it's very important that we keep monitoring in the same way we monitor when we rolled out a new drug to see if our new policies are having the intended effect or if there's something we couldn't anticipate and then make course corrections that we need to. >> i would like to comment on the next person. i read a lot about that issue of the opioid medications and the use of chronic pain management. i get e-mails from physicians and it says we the recommendations of not using upright as a first line of treatment which is the cdc guidelines are saying. the problem that we have is that not all of the insurances cover for it and in the paperwork that is required in order to justify some of these alternative treatments are considered the first line of treatment for some of these pain conditions are not accepted by the insurances. physicians cannot do the right thing because it's more cheaper to prescribe in opioid medication. so, one of the things yes, we need to have physicians use the proper use of upgrades but we need to struggle put changes into our healthcare system. otherwise, they the guidelines if someone is not going to help the patient they will be giving that intervention. that is an aspect that we need to also be very aware of. we generated a system that has treating. [inaudible] >> thank you. yes. >> dylan, the press. in the past, the government of china does not appear to have been very tough on cracking down on suppliers of synthetic opioids but i'm wondering if there's any evidence now that opioids addiction of this sort is spreading in china itself and might that lead the government to become more serious. >> i don't have any evidence for that and i know that stimulants are very popular, used and abused in southwest asia. but it hasn't worked very effectively for drugs like cocaine and heroin in countries that have a lot less in the world and china does now. >> we were trying to create a new model for patients with. we see the consequences so i ask have you seen an increase in the overdose pointing out the fact that you are mixing heroine with fentanyl and he didn't know about it. so again i think that the issue is very difficult and we have the abilities of those that are much faster otherwise i do not know the extent to which there is a knowledge of the problem [inaudible] >> as a basic scientist i get the value both fundamental and clinical and we are doing our part at the university to better educate the professional approach but it's disheartening to see 17% that are privately insured and we don't have at least some effectiveness you start to look at the populations under served in the communities and they are even more striking against us. take that a step further thinking about the demand in connection with social bonding for example. what's going on in the society and who will address some of these things that drive people to take a variety of substances or certain behaviors in excess that harm than and the community, who is going to take responsibility for that? >> the first part is we either have or will have a severe labor shortage. there is simply not enough providers and providers are not distributed in a way that made the problem. i just had west virginia in my head. so promoting medical education, the residency, it also could help the programs whether it is load repayment are moving into psychiatry, mental health, addiction, medicine would be tremendously helpful. the second question is looking at what are the deeper issues of this because i agree that the excessive prescribing caused the effect that we are in and i love the example, but there is a reason why this epidemic settled in the areas that had settled into. there's multiple overlapping comorbidities that say something about the segment of the american society and whether it is the disenfranchisement and the lack of opportunity and the lack of hope and despair that is binding up that is a much more complex set of problems we need to address the. the area might be culturally shifting to one use of the institutions but may not have the personnel to do it we could use creative approaches, so the epidemic we could address and turnaround. >> i would like to reiterate that because i actually look at it from the perspective of what is the challenge that we have in addressing we know how to do it. we have a roadmap that would implement a and if someone were to tell me how you would address the problem i wouldn't even know how to start. we wouldn't have treatment or know how to properly prevent it so here we have a much better understanding. we know how to prevent it and how to treat it but it's a very integrated approach. we've been very successful. look at how we have dramatically reduced it. it's going to require an investment putting a billion dollars of treatment in the disorders which is fantastic we've never seen anything like that but the problem is we want to be sure that it goes for evidence-based treatments which isn't something we speak much about it. we need to demand that as a way to the disorders o have the disy other addiction. >> this one and then we will adjourn. >> thank you for your time today. we have two short questions. one builds upon what you've been talking about but i want to ask whether it is the mining industries were others that have been degenerated in the past few years and they also face a transition crisis when they come out and i was just wondering about the program now it seems that there is a lack of communication overall in the transition so i was wondering if you touch upon that. >> from the statistics among persons age 1 aged 12 or older m sorry, 2015, it is a 26 million, cocaine is 968,839,000, lsd is 164,000 methamphetamines or 225,000 whereas heroine is pretty low at 125,000 so just wondering, the las last slide td separating out the problem from the overall pain relievers. from these statistics it appears it is quite low on the scale and it may be doing a disservice. >> may i take the question first. >> we have to be brief about the answers and questions. >> i would like to thank you for your service and just ask you to please look up the department. we are a huge organization and we do have a transition care programs so that the veterans that are leaving the dod can engage in health car healthcared we also have programs for education and employment so please reach out to us and let us help you. >> [inaudible] thanks for bringing up the fact this is one piece of a larger issue. marijuana isn't a deadly comic heroine just happens to be deadlier than a. we need to address it or we'll l lose a piece of a generation. i was wondering if there was any research on the overlap between overdoses that may also be suicides and thinking of it as a major public health crisis right now do we know what kind of research is being done and how do we separate a bat and how can it be treated by substance use treatment and those that may require more specific suicide prevention intervention. it's relaterelated not just to e but also the increase of the suicide. we also know those that suffer from depression if they are taking opioids, there is that suicide is much higher. so there is a very strong relationship between all of them and one of the things the guidance tells you a guess having a history of depression. because they prescribe you in opioid, the rate for suicide particularly if you are a woman is a huge effect suggesting these overdoses and of course we are seeing intentional overdoses and there is really no way we can distinguish. i think it is one of the more important. [applause] michael crowley writes over the firing the president and secretary of state welcomed the foreign minister on tuesday president donald trump fired his fbi director and made a federal investigation into the ties with the kremlin. wednesday he welcomed the foreign minister and the controversial ambassador into the oval office for a friendly meeting to discuss improving relations between the two countries. the story goes on far from showing signs of tension and discomfort. he was seen in photographs smiling and laughing with foreign minister laffer and the contact with the former national security adviser this was the subject of a dramatic hearing on monday. again that is on politico.com. now you look at the secretary of state meeting with russian foreign minister lov lavrov