good afternoon and welcome. 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 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 . . . . . . . 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. now, this slide i apologize. what i would like to point out an the graph is that the medication assisted treatment reduced mortality for those with opiod use disorder. it's not just overdose mortality. so, what are our challenges and next steps of getting this life saving treatment to those who need it? among patients hospitalized for opiod use disorder only%. can you imagine if we treated diabetes the same way? 54% received services following hospitalization but 40% received no continuing care. according to treatment episode data 27% of treatment plans for heroin use disorder. in the va patients who are clinically diagnosed, where ever they present, 34% received medication and fiscal year 2016. so we can anticipate demand is going to continue to increase and our next steps are on how to desimilar nate why they are available. the good news is as demand has been increasing some of the we made to support them have increased and then i would like to just present to you four evidence-based models that we might follow. one is grief counseling is sufficient. they randomized patients in primary care to receive physician management, this brief counseling that i mentioned before either once a week tapering to monthly for stable patients or received it with an additional hour of counseling. almost 80% retention in treatment at 12 weeks and four to five weeks of continuous absten nance. it really didn't make a difference as long as the medication was prescribed with close monitoring and the grief counseling by the prescriber. i think it's an opportunity to do this more widely. similarly a very similar model to general mental health care settings. what they found was while patients were engaged in treatment their chances of remaining sober were ten times greater than after it was taper off at the end of the trial. this is the so-called massachusetts model. they have taken the model and instead of the physician or prescriber doing counseling and they work within a team and they have been able through that model to increase the number of patients. and then another similar but different model in the state of new mexico that was heavy hit, the state of new mexico realized they needed to out to areas quickly. they developed a model in which they had a weekly meeting, basically clinical rounds like you might have done in medical school. with that consultation and training they were able to dramatically increase the availability of medication assisted treatment. and then finally i'll mention this one model that's from the alcohol literature. he randomized patients to receive alcohol care management again with care managers. as they prescribed it for treatment of alcohol use disorder and they found that those who were randomized to receive that primary care not only were they better engaged in treatment because they didn't have to pass from one clinic to another but their percent of heavy drinking days was superior as usual. i'm very hopeful we'll be able to do that and one key partner is academic detailing in which we use the same techniques that they use to promote new products to promote evidence based best practices. and they helped partner with our overdose and this is just a graph that since 2014 when we started this we have actually d d dispensed over 71,000. at this point it is over 75,000 rescue kits. so potential next steps, i think there's a lot more to be done in terms of implementation science. we have actual treatments that work pretty well that 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 even better medications on the horizon. and how we can enhance education. right now in order to be able to prescribe physicians have to take an eight hour training course. nurse practitioners have to take 24 hours of training. that seems like a burden for someone with a busy clinical practice. why is anyone graduating from medical school without that training? that's one area we could improve. we could also let folks in the field try some of these models for implementing like they have spoke and learn from those and apply the lessons learned to continuously improve our processes. so opiod use disorder is preventable. we do need more help for newer better treatments as well as how to implement the ones we have. thank you. >> would you come up? we'll take questions from the audience but you need to line up. there are microphones in the two aisles. when i call on you please give your name and affiliation status. i wanted to ask a question. well with, let me start with karen. 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 opiods. let's stick with opiods. >> okay. there is an increased risk for chronic pain among veterans. i don't know off the top of my head about whether we prescribe opiods more for patients who have chronic pain. >> it does make sense they have more chronic pain. they have had very physically rigorous -- >> yes. >> my son did that. >> one of the things we have come to recognize is there are some people that are more vulnerable to become addicted than others. what physicians always want to know is let me know if i'm going to prescribe them, are they going to be at higher risk or not. we know it is genetic but we don't have the genetic tests that can help us. there are many things that we can actually ask patients that can give us an idea of their risk. one of them, have they been addicted in the past to drugs? they had a prior history of addiction or certainly opiods should do that. also, age. we know the younger you are the greater risk you may have of becoming addicted. this is one of the reasons why in general opiod medication should not be prescribed to teenagers unless they are necessary. and so family history is also a factor that contributes to that. mental illnesses can increase your ability to becoming adilkted addicted to drugs. at the end of the day there is nothing that can guarantee you a patient is not going to become addicted. there's factors that tell you if someone is at greater risk. if someone is going to be prescribing opiods repeatedly it is required they are monitored very carefully, every time that they evaluate to be sure there is not any development of misuse of opiods or abuse. >> dan, i wanted to refer to show heroin users. are they just what you know, are they just people who are switching on what would have been somebody else years ago but now heroin is less expensive or something like that or are these attracting new people who would have been addicted to another substance? >> just like the previous question, you know, the answer is complex and not completely known at this point. if they can have this sort of wave effect. it increases and we tested the size of the population by prescribing opiod pills. but what i would like to answer is with an anticdote. in my observations my team and i have been to mill towns and outside of boston, lawrence, baltimore, chicago into west virginia. we see a lot of new people out there. the new people aren't necessarily coming from prescription pills anymore. there is a new wave that are coming in. they are young. i'm not sure whether they would have done another drug if heroin wasn't the thing now. i do know there's a mixed picture right now. there's also a cultural wave, another anecdote, nice guy, works, happens to have a daily heroin habit. he went back to his ten year high school reunion. small town, everyone knows everyone's business. everyone knows who stayed and who died. half his high school class is gone. the first time in 17 years i almost had to stop an interview. pills and marijuana, one or two motor vehicle or industrial accidents but mostly pills and heroin. there's something very large out there happening right now. there's no easy answer. >> okay. let's take some questions. go ahead. >> thank you. i'm the chief of ethics policy at the veterans health administration. i wanted to add that one of the things we did in our policy on long-term opiod use is to reduce pain agreements or pain contracts. we felt they were unenforceable and adversarial. we substituted a robust consent process so that patients get a good conversation about the risks, benefits to long-term opiod use. the two questions i have are about integrating policy strategie strategies. so patient satisfaction surveys, i have heard from clinical providers they feel pressured to prescribe all drugs but in particular analgesics in order for patients to give them a positive satisfaction rating. and the second was what about third party insurance coverage for opiod use treatment and what can be done to encourage other players in the market to get onto this initiative. >> do you want to take that? >> i'll take the first one. i'm not an expert in third party payers. >> i don't think any of you are probably. >> okay. but i am on the steep end of the learning curve about unintended consequences of policies. it's a little like safety trials. you do phase one. and if they are positive you monitor to see what happens out in the real world. i read a paper just this past week that about a third of the adverse events that we know about we learn about after market, after the fda has approved. i think the same thing happens with policy. we do our best, as you saw, to create policy based on the science of what seems like it will work. when you rule it out in the real world you don't know what's going to happen. i think it's very important that we keep monitoring in the same way we try to monitor when we roll 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 make course corrections as we need to. >> i will comment on the second question. it is not that i'm an expert on insurance but i read a lot about the issue of opiod medications and use for chronic pain management. it says we completely agree with you of not using opiod as a first line of treatment. they say the plob that we have is not all of the insurance actually covers for it. in the paperwork in order to justify some of these alternative treatments are not accepted by the insurance. so yes. we need to educate but we need to do structural changes into our health care system such that the proper treatments are covered by the insurance because otherwise you can write all of the guidelines that you want. if someone is not going to reimburse the patient they are not going to be given that intervention. so that is an aspect that we need to also be very aware of, that we generate the way of treating that actually facilitates prescription of opiod and other interventions. >> thank you. government of china does not seem to be very tough, but i'm wondering if there's any evidence now that opiod 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. i know that stimulants are very popular, used and abused in southeast asia but not necessarily synthetic opiods. there is high-level agreements to restrict a number of its cousins from being produced and exported from china. i would have to say though my own personal opinion is fairly cynical in that. i'm not sure how one effectively controls the tiniest fraction of an elicit production in a country with an enormous tr industrial capacity. >> i was in china last year and they have of course a problem with heroin abuse. they have been actually quite successful and he kid not know about it. so i mean again, i think that issue is a very different country and they have abilities of implementing interventions in ways that are much faster. the other one, i do not know the extent for which there is not great knowledge of the problem it was 17% that are privately insured are getting treeatments. you look at underserved medical securities. those are more strikingly against us. or do certain behaviors in that harm them and also the community. who is going to take responsibility for that? >> dan, do you want to take we responsibility for that? >> i'll start. so i think we have or either will have a severe labor shortage in substance abuse treatment. there's simply not enough providers and the providers are not distributed in a way that meet the problem. it would help whether it is loan repayment or others that would promote a generation moving into sigh chi tree, addiction medicine would be tremendously helpful. as far as the second question goes, i'm writing a paper right now looking at what are the dooper root issues of this? i love that we need to take the handle off the water pump. but there is a reason why this epidemic settled in the areas it has settled into. there is multiple overlapping comorbidities that say something about this segment of american society whether it is poverty, lack of future, lack of opportunity, lack of hope there's some diseases of dispair that's lining up through the midwest and over eastwood that is a much more complex set of problems that we need to address. thanks for bringing that up. it makes it a little -- i'm feeling a little sense of dispair and hopelessness too. we have this evidence base. we have the tools. we have the ideas. we need resources and a creative way to take resources and apply them into the regions, you know, telling medicine and that kind of thing to get them to the areas that might be culturally shifting to want to use substitution therapy but may not have the experience or the personnel to do it. we could use creative approaches to get that. so specific epidemic i think we could address and turn around. i actually look at it from the perspective of saying what the challenge we have in addressing the opiod epidemic. we have a road map that if we implement we will succeed. we know how it grows. we know how to prevent it. it does require a very integrated approach of resources to do it. >> we can do it. one thing is we have the 21st that is putting billions of dollars which is fantastic. we have never seen anything like that. the problem is we want to be sure that goes for evidence based treatments, for quality ca care. i'll take this question and we'll go and enjoy our reception. >> yes. from johns hopkins university. thanks for your time today. two hopefully short questions. one actually builds upon what you have been talking about. whether it is mining industries or other industries or any industries that seem to have -- have been degenerated in the past few years for new jobs. i think veterans also face a transition crisis. i was just wondering, i do get messages from the va. it seems there is lack of communication at the overall transition as they go in and out of different health care systems to understand what are some of the risks. i was wondering if you could touch upon that. you mentioned a lot of time today about heroin. from the statistics of 2016 which are discussing drugs among persons age 12 or older, marijuana is a 2.6 million pain relievers in general are at 2.1 million. it is about separating if heroin problem from overall pain relievers. from these statistics it appears it is quite low on the scale and maybe just doing a disservice, i would love for you to touch upon that. thank you. >> okay. may i take the first question first? >> yes. we are going to have to be brief in our answers and brief in our questions. >> okay. >> so i'll be as sas possible. i would like you to google department of va. we are a huge organization and we do have a huge care management program we also have programs for education and employment. please reach out to us and let us help you. >> great. and, you know -- [ inaudible question ] >> you know, this is one piece of a much larger issue about american society. there are other drugs of misuse and abuse, some of which are very common. marijuana is very common. marijuana is not deadly. heroin just happens to be deadlier. one is alcohol. we have to remind ourselves working with teens to reduce progression from what might be light level of alcohol use, recreational use or normal social use to not progress. people there are testing their genetics. you know, alcohol is highly genetic predisposition. people should magnify resill yans factors to not progress. i happen to know heroin well. we are in a death wave with heroin. i was wondering if there was any research before overdoses that may also be suicides and thinking of suicide as a mayor public health crisis right now, do we know anything, what kind of research is being done? how do we separate deaths that can be treated by substance abuse treatment but also those that may require more specific suicide intervention? >> very important question. we don't know exactly what those numbers are. so from those 33,000 deaths it is possible. i think i wouldn't be completely off the mark. 15% of them are related to suicides. we know that the loss in years in terms of your life span expectancy in the united states that we are seeing in middle-aged white people is not related not just to the overdose but to increases in suicide. we also know if they are actually taking opiods they risk is much higher. there is a very stronger morbidity. one of the things that the guidelines tell you among the factors that are associated with higher risk of overdose is having a history of depression. if you are depressed and they prescribe you an opiod your risk for suicide, in particular if you're a woman like 8 or 10 fold higher is huge. in many of these we are seeing intentional overdoses. there's really no way we can distinguish one from the other. >> well, this has not been the most cheerful of events that we have held with the dana foundation. i actually do think it is one of the most important can attest to that. so before we go off to the reception i would like to take one more chance to hank the foundation for all they have done. [ applause ] >> michelle obama will talk about combatting childhood obese di for a healthier america. we'll have live coverage at 10:30 eastern time on cspan and the cspan radio app. sunday on q and a, the cam pair sons between donald trump and andrew jackson. i would tell mpresident trump h has to put nation in front of his own person hood, in front of his own family, in front of his own interest because that's what jackson did for most of his presidency. >> sunday night at 8:00 eastern on cspan's q and a.