Public Health Effects of opioid addictions and Treatment Options available. This is just over an hour and a half. Good afternoon and welcome to aaas. Im charles dunlap, interim director for the center of science policy and society programs. Our lecture this afternoon on the Opioid Epidemic is the second in the 2017 aaas Dana Foundation lecture series on neuroscience and society. Our first lecture this year on the brain and video games was held in march and our third lecture in september will be on meditation. So please keep an eye out for the announcement date. The Dana Foundation is a private Philanthropic Organization that supports Brain Research through grants, publications and Educational Programs like this one. For the last five years, aaas has partnered with the Dana Foundation to present an annual lecture series on neuroscience. By my count, this is the 20th letter in the series. Were grateful for the Dana Foundations support of this series and for deborah runkles leadership of the series in our scientific responsibility, human rights, and law program. With that, deborah . Thank you, charlie, and welcome. It seems to me that hardly a day goes by that there isnt some story i see on the tv or in the nund that i see about the opioid crisis. As i was thinking about that today and leafing through the paper, sure enough, on the front section of the Washington Post is a story about how the governor and washington, d. C. s mayor are forming a combined database on prescriptions and who is getting these drugs. Its just another day. A few days ago, somebody sent me something that said that in an in a small town in kermit, West Virginia where 392 people live, a pharmacy there received 92 million pills of opioid painkillers. 92 million seems a lot, doesnt it, for a town of 392 people . So theres really a very bad problem going on. And we are going to address it tonight, looking at it from several different points of view. And by the way, when were all done, i want you to know we do have a reception planned, so for the end of this. So tonight were going to look at an eagles eye view of the Opioid Epidemic, a more closein view from the National Institute of drug abuse, and then talk with Karen Drexler of the va about possible treatments. Our first speaker is dan ciccarone, a professor of medicine from california, san francisco, who specializes in Community Medicine and treating diseases in poverty. He was a leader in the hiv aids epidemic in the early days. Hes going to talk to us tonight, as i said, an eagleeye view of the scope of the problem. Dan . Thank you, deborah. Is there a direction to get the next slide up . The screen is up but not there it is. Oh, there we go. So im a typical academic and i cant even begin to talk until my slides are up, you know, im little lost without them. Hi, everyone. Dan ciccarone, ucsf. Yes, im a Family Community doc, so my perspective is one of trying to see ways to improve community health. I started with the hiv epidemic but found my way to the drug epidemic a few years ago. Im here tonight to talk about prescription pills, heroin and fentanyl. Did the wrong thing again. Lets try it again. Voila. So i want to go through some epidemiological data on the opioid overdose epidemics, comparing prescription pills with heroin, looking at some demographics and epidemic curves. Ill also spend a little bit of time talking about the illicitly manufactured fentanyls, one slide on etiology and one slide on other consequences. Yes, got it. Most of what im presenting is publicly available data, cdc and the dea, for example. A little bit is going to come from my study, heroin in transition study funded by the National Institutes of health, National Institute of drug abuse. For the First Time Since 1993, the u. S. Death rate has gone up year to year. 1993 was the handwriting of the hiv aids epidemic. And here we have the ten leading causes of death as of 2015. Heart disease and cancer are the two big elephants in the room, sort of cancel each other out, one went up, one went down. If we go to number four, unintentional injuries, we see a clear bump up, 2014 to 2015. We were shocked in 2011 to find out that two of the leading causes of Unintentional Injury death had crossed over, with drug poisonings on the rise and Motor Vehicle accidents on the decline. Of course this is good news for Motor Vehicle accidents but bad news in terms of the drug epidemic. This is a graphic from the new york times, i was working with josh katz on this. Drug poisoning overdoses, number of deaths have now exceeded car accidents, gun violence, and even hiv. You can barely see the hiv line there, i apologize. Its a steep rise up. Its peaking around 1993 and then a decline. Weve moved from epidemic, drug poisoning or Opioid Epidemic, to a crisis. Looking at hospitalization data, this is the curve for the overdose epidemic. Dramatic rise up, 1993 to about 2011. Some good news, plateauing, perhaps even a decline post2011. This of course is based on the work were doing to restrict excessive prescribing practices. Unfortunately this is now heroin overdose hospital admissions, dramatic increase up since 2008. Its not necessarily the magnitude in this slide with that sleep curve that has me concerned. Year over year, no end in sight. Whats fueling heroinrelated overdose . Three possibilities. One is theres evidence that the number of heroin users, the denominator, is rising. And theyre coming from two paths. One group is coming from opioid pill dependency, finding heroin is more available and cheaper and replacing their high level of pill dependency with a heroin dependency. Heroin is cheap, its pure, its good, and it is everywhere. The supply has changed dramatically in the last few years. Places like burlington, vermont, are not supposed to have good heroin, and they do. My group has several stories, intertwined epidemics, we used that term as early as 2012. One group of opioid users could transition back and forth. Thats because the opioids are treated equally in the body. We also wrote a story about folks who are on heroin and they transition. With the new users and young users telling stories about how they started with pills and then moved over to heroin. This is a picture i took in an alleyway in philadelphia just to sort of symbolize the pill to heroin intertwining. And heres some data from my group looking at comparing the demographics by age for these epidemics. Here is the pill overdose problem. Predominantly, 20122014 data, this is an older age group, whereas for heroin, a younger age group. We show a rising problem among young people, there we have it. But if we shift this over, we see some evidence of the intertwined or transitioning between opioid pills and heroin. As the opiate overdose year to year rate goes down, you can see from the blue to the green, we see that heroin overdose is going up in that same age bracket, 2012 to 2014. By geographic region we see a starker difference. Opioid overdose is relatively even across the country over a long time period here. We like to think its worse in places like appalachia, but to our eye they look more or less even by region. That is not true for heroin. Heroin is dramatically different. The northeast has had a problem for generations with an endemic issue with heroin. The midwest, the red line, which is now highlighted with the gold arrow, going from low levels of heroin overdose to very high levels of heroin overdose. Clear geographic disparity that cannot be explained by a simple opioid pill to heroin transition among the population at risk. So in addition to that story, we have to tell another story, that heroin is itself becoming a more dangerous drug. It is being adulterated, contaminated with synthetics such as fentanyl, and its coming in a new form, which has received very little press. Lets talk about fentanyl. Fentanyl is integrated into the heroin supply. You dont go to a separate corner down the street and ask for some funny street name for this new drug called fentanyl, right . You go and by heroin, and the heroin you get, if youre in that right region, the right mill town in massachusetts, for example, youre going to get fentanyl contaminated heroin, a potent synthetic opioid, 100 times more powerful than morphine by weight. Its appearance, weve had multiple appearances in the past, but the latest appearance has been a long one, longer than the other waves, began in late 2013. Its illicitly manufactured pharmaceutical. Its analogous with what we saw with an adulterant, it is now ubiquitous in the cocaine supply. This implies there may be a future for the heroin plus fentanyl as the new heroin moving forward. In addition to the main chemical which is fentanyl, there is at least two dozen analogs. And in addition theres other novel synthetics like 4700. Carfentanil, the big bad boy were worried about, carfentanil is the big one. A thousand x morphine, three to 400 times as strong as heroin. This is not meant for human consumption, its a large animal pain reliever. So if your elephant has a problem. The illicitly manufactured fentanyls are coming from china, through multiple routes in north america. The predominant route for heroin is through mexico and coming up through cartel distribution. Where is it going . These bottom seven states are places that have both high fentanyl supply, according to the National Forensics lab, and high rates of opioid deaths, midwest, appalachia, new england, the same as for heroin deaths. One reason why we got here, its called supply side theory. When morphine and heroin were synthesized and promoted as pharmaceuticals, they were quickly adopted because they worked. They did what people wanted them to do. But they also became problem drugs. So we have novel drugs, Technology Advancement in terms of synthesis and Technological Advancement in terms of the invention of the hypodermic needle. Weve had waves of heroin, use, misuse, and abuse over the generations. Some of which have been cultural. Some of which have been related to new sources. So the vietnam era heroin epidemic, devastating u. S. Cities. That was a new source of heroin, type 4 heroin coming from southeast asia. The colombian wave came when colombian drug cartels brought in heroin in 1992, which led to a wave of problematic drug use in the United States. Now we have the opioid pill problem. Again, iatrogenic, a novel form, high doses of powerful opiates. Theyre easily abusable, crushable, dissolvable, injectable. Heroin is coming in now, early 2000s. I havent spent a lot of time talking about it, but mexico is producing a highly potent powdered heroin that hasnt been seen before. Synthetics are also coming in, a new source and a Technological Advancement in that its highly potent. Ill remind everyone there are other consequences besides overdose in this opioid crisis, injecting drugs leads to Infectious Disease risk. Blood borne viruses, hepatitis c and hiv. We should be mindful of the scott county the severe hiv outbreak in scott county, indiana. There are many scottcountylike counties in the United States. We also have to be concerned about bacterial infections, soft tissue infections, that cause a lot of suffering. It costs us a lot of money in terms of treatment. All of these things are preventible. These numbers hide the pain, the experience, the resilience, the coping thats going on among the user population. We meet with users in the street. We watch them as they prepare their drugs and inject, all the while fascinated by new chemicals out there, they come in new forms, new colors of powders, new colors of powders. Solutions, this bright yellow solution freaked me out, and ive been studying this for years. If its freaking me out as a Public Health researcher, you can imagine what users are going through. They want our help and its up to us to provide it. We need to treat heroin and fentanyl differently than were treating the prescription pill problem. Supply shocks can lead to epidemics. Unfortunately that does not mean were going to put the genie back in the bottle or that supply is the only answer. Yes, this is a crisis of epidemic an epidemic of crisis proportions as were besting the hiv epidemic at its worst, unfortunately. Its also a crisis of opportunity. We turned that hiv epidemic around. Look at that dramatic drop down. This is the effect of appropriate government cultural social intervention treatment and prevention. Treatment and prevention worked for the hiv epidemic. Treatment and prevention will work for the heroin and fentanyl epidemic as well. We should not treat these epidemics the same anymore. Controlling prescription pill practices, prescribing practices we can do, a lot of effort out there, it can work. We need better surveillance. Hint, we need to treat this as a poisoning epidemic. Were counting the dead bodies as they lie. Were not testing. We need more evidencebased treatment. Methadone and buponorphrine. We will need faster responses to overdose. Naloxone needs to be in the hands of paramedics. Its in the police tool bet, great, fantastic. We need to get it to peers, to users, to families. It needs to be this generations epipen. Its Cost Effective and can bridge people into treatment. We tend to think of Harm Reduction as aiding and abetting reduction as aiding and abetting drug abusers, in the political sphere. Harm reduction saves lives and can be a bridge to Clinical Care and to treatment for the affected individuals. And Public Safety and Public Health collaborations, sort of the new mantra, this can happen. Okay, we need to work with the criminal justice side of things and Public Health side of things, stop treating drugs as the sort of the special privilege of the criminal justice folks and the injured bodies as only Public Health. Both sides need to work together. And with that, ill end. I particularly want to acknowledge the university of maryland who was the statistician on this project and thank you all for your kind attention. [ applause ] that was a good intro for our next talk which will be coming from the government. Im anxious for you to hear how much the government is doing. Our speaker is nora volkow, the director of National Institute on drug abuse, nida which is one of the National Institutes of health. She has been a true pioneer in the study of the physiology, the pharmacology of drugs of abuse. And she will tell us a bit about what those drugs are and what her office is doing. Good evening, everybody. Its a pleasure to be here. I think that ive been here several times. Last time it was actually, we were discussing the issue of marijuana and how all of the changes in policies was going to affect the potential negative effects. Today were speaking about the worst crisis weve ever seen in the United States that relates to a drug. What is interesting about this crisis which actually is very, very tragic, is number one, first of all, different from any other epidemic that we have had in the past. This one basically came out of the Health Care System. And it came out of very good intentions which were we need to treat those patients that are suffering from pain. And this can be a serious devastating disease especially if it was a severe state. It was recognized there was a concern that patients were not being treated properly for their pain. In the late 90s, in the beginning of 2000, it was decided that these would be the area of pain treatment. And among the many actions that took place was the joint Accreditation Commission which actually credits hospitals, demanded that we recognize pain as a fifth vital sign and that you treat it. This was coupled with a strong emphasis on the need to treat patients at the same time there were limited therapeutic interventions that can be used for pain. And that of course resulted in the massive expansion in the prescription of opioids medications. There was also many in the past there has been a lot of fear about the use of opioids for the treatment of pain because of the fear that patients will become addicted. That shifted dramatically at the beginning of 2000, and with very strong advertisement from the pharmaceutical industry to encourage physicians to prescribe opioids. With the notion that we were taught in medical school and this was taught until very, very recently that if you have pain you are not going to become addicted to your pain medications. We as physicians became basically confounded about what we have learned in the past it could produce addiction and now we were faced that we needed to treat them, that these drugs were not being addictive. Unfortunately the numbers as physicians start to prescribe more and more opioids, it became clear that that was not the case. And as you look at the numbers backwards, its always easier to look at things backwards. I came in 2003, one of the first things they were showing me was results of monitoring the future. Monitoring the future is a survey we do with teenagers. What struck my attention immediately in 2003 is that the rate of use of prescription opioid, vicodin was 10. 5 among teenagers. And i have never, ever seen, and im a psychiatrist, in my life a teenager taking an opioid. And thats what caught my attention. And when we started to look at the numbers, we started to realize that there was a massive abuse of prescription opioids across all ages. But it was almost like people were not listening to us, what we were saying, we have a problem with prescription opioids because there was a sense that they were safe and there was at the same time immediate counterreaction that you dont want to jeopardize the proper treatment of patients with pain. And it was not until we started to see numbers like this one that then the agencies realize, my god, we have a serious problem in our hands i dont think anything speaks better, when you start to see numbers like these that grow so rapidly. The overdose death rates from the cdc, you can see 1999, there were some pockets of the United States with very high overdose rates. In particular you can see the appalachian region. And over 14, 15 years, the whole United States appeared to become infected. You still see the main areas for overdoses in the appalachian region. As with the prior speaker, we see areas in new mexico that in the past had not seen it. And now im actually waiting for the data on 2015, because i actually were starting to see further expansion into the northeast. Now its driven by the emergence not just of pure heroin but also fentanyl and fentanyl synthetic opioids. So why is it that opioid prescriptions trigger such an avalanche of overdoses and deaths . This is the tip, because underneath it of course there were multiple adverse conditions associated with the use of prescription opioids. Opioid medications actually, there are a wide variety of them, but they all have a common pharmacological effect. They basically are agonists. The opioid receptors are all over our body. And they are actually associated with this brain image that shows using tomography, showing the high levels, the cold scale showing the lower levels where they are located in our brains. As you can see that there is a very high concentration in all of the regions of the brain that are engaged in our ability to perceive pain, what we call the pain network. And that includes the acc. The thalamus, the central area in the brain. And the which is fundamental for our ability to purr conceive pain. There are mu receptors in the amygdala which is involved in the emotional processing of pain. It is fundamental for the emotional negative reaction that we get with pain. And that area is also loaded with opioid medications. When opioid medications inhibit the perception of pain, this is the reason why opioid medications are probably the most effective medications that you can have for addressing severe or acute pain. They act almost immediately. The issue was that acute pain is something that you may one of these drugs may save your life. I dont know if any one of you has been given them. I have been in a car accident and i wanted to actually go unconscious, i wanted to faint because the pain was so intense. Then they gave me an opioid and it was like magical, it was an extraordinary sensation of wellbeing. Not only that pain was gone but a great, great sense of euphoria and relaxation. And thats why these drugs are problematic. They are not just located in the pain centers but they are located in that area over there and this region is one of the most important regions in feeling pleasure. In individuals that do not have an adverse and rx they creactio. We have these mu opioid receptors in the lower brain in the black. And thats where we have nuclii. That inhibit breathing and thats why you can die from an overdose because you stop breathing and this gives exactly the reason why opioid medications are far from being ideal as treatmented not in one instance for acute pain but the problem emerges when you use them for the management of chronic pain. Chronic pain is considered when you have pain that lasts longer than three months. They are effective when you give it acutely. But when you give an opioid drug your body rapidly becomes tolerant of it. And the higher the dose you get, the higher the likelihood that you become addicted. So the rewarding effects of the drug, actually when they are experienced repeatedly leads to a consider in response that leads you to crave that drug and in those that are vulnerable it leads to a loss lot of control. And also because the tolerance to the effect of opioids in the brain do not occur at the same rate in the brain regions, they are faster for pain and for reward. That the rate of they occur in the breathing center which accounts for why these medications are far from ideal for the treatment of chronic pain. You need higher and higher doses and the higher the dose, the greater risk of addiction and the greater risk of overdosing from sleep apnea. What generated the epidemic . It related from our overprescription. And there was in 2013 there were 235 million prescriptions in the United States. Sufficient amount to provide one month supply of opioid medication for every adult in the United States. You say maybe the United States, the adults of the United States are from severe pain if you look at the stati the united stat actually prescribes between 80 and 85 of all opioid medications in the world. So this led to the recognition were overprescribing. Overprescribing, facilitated the diversion of these medications that then had a black market and started to be abused and that then led to addiction. You generated from two roads. People that were given these medications, for pain, by the doctor that they will not become addicted because they had pain become addicted and those who started to experiment with these drugs because of their rewarding effects and these two ultimately generated a similar syndrome of addiction, control over drug safety and the escalation of drug intake. So there was a massive amount of effort in trying to actually train physicians in proper prescription of opioid medications. Because when the joint committee came in 2000 it was not associated with training on how to use these drugs. So physicians were starting to prescribe with no knowledge. So now we know, for example that there are certain prescription practices for opioids that are particularly risky for overdose. When you give more than 80 morphine equivalence, when you mix these medications with other medications that depress your breathing or mix them with alcohol and yet we are still prescribing these medications with one another thus increasing the risk of overdoses. Overall were seeing changes in the right direction, 15 decreases in the amount of opioids being prescribed. Between 2010 and 2015. This is not a major change, but its still in the right direction. Unfortunately, this does not in any way change the overdose rates that have continued to escalate, very much in line with what youve heard in the prior presentation. Here you have last year, more than 33,000 people die from an opioid overdose. When you see the commonly prescribed opioids, they are not going down, they are stabilized. What is going up is that line of heroin and other synthetic opioids. Synthetic opioids is mainly fentanyl and its analogs. Aaron is actually the the result of as we look at in terms of what is driving these high rates of overdoses . For many, many years in the United States, we have very, very stable, low levels of abuse of heroin in this country. And the rate of death was basically you look at it, so constant, 2000, people dying every year from heroin. And then the amount of heroin, you start to go up. It wasnt dramatic, not dramatic, its actually around 700,000, 700,000 coming from 500,000. The number of people has basically quadrupled. The ones dying. What is driving this . Were driving it, we have a much purer heroin thats accounting for the very high rate of overdose. And its a different population. Were seeing the young rural areas affected the most. So in the meantime, were seeing that this heroin is being laced with fentanyl. And fentanyl as you heard before is extraordinary potent or with other synthetics and thats what is driving the massive amount of Overdose Deaths. Of those new heroin abusers, 80 of them started abusing prescription opioids. If you analyze really what happened and how the heroin was deployed coming from mexico, all the heroin in the United States is from mexico, actually it started in states where it actually has the largest problems with prescription opioids. Those individuals that did not became addicted to the prescription opioids for them it was cheaper and easier for them to go to heroin. So 80 of the new cases are from people who became addicted to prescription opioids. This is important to address. What you dont want to communicate is if we want to contain the heroin epidemic we should make prescription opioids more available. That is exactly the incorrect answer. In order to address it we have to prevent abuse and diction to prescription opioids. It would prevent them not to transition to heroin. And these are the numbers that you saw in terms of how when a drug we know that for any drug that is out there, that the price plays an important role. We are getting heroin from mexico that is coming with an extremely high purity and increasing dramatically the price of heroin. The price of heroin in the United States is going down. And fentanyl is quite easy to sen synthesize and it is so potent you can bring it in small volumes. This poses a tremendous amount of challenge because you are not carrying big volumes, you can carry these very small amounts of drug that can produce a multiplicity of doses. Of course this poses tremendous challenge not just from the supply perspective but poses tremendous challenges from the Public Health consequences associated with the overdose, the very, very high risk of overdosing with these drugs. What is it that nif ah and nida doing . When we had the hiv epidemic and ebola epidemic we control it with science. And its not any different for the opioid crisis. The way we review it is we need to understand the root cause of the problem that we had a problem with patients suffering from pain that we dont have many alternatives and in particular the problem is for the management of chronic pain. In the United States approximately 100 Million People suffer from pain moderate to severe. We need to develop better treatments and safer for the management of chronic pain. The other is we need to do interventions that can actually prevent the overdoses. We have other drugs. But we need to actually go and design alternative strategies that can help the individuals that we are actually reverting from an overdose because otherwise theyre going to overdose again. Finally, we need more treatments for opioid disorders. We have bupronorphine. And we have vivitrol. While that is very, very useful, it is not sufficient and ill show you why. In the area of pain here you say we have an incredible opportunity. 100 Million People are suffering from pain and yet we dont have many medications. And for many, many years pharmaceuticals have actually poured millions of dollars into develop an opioid medication that would not be addictive. And this was this resulted in zero results. What many of the pharmaceuticals from the development of pain medications. Now science has recently with the ability to look at and identify the three dimensional structure of the mu opioid receptors you can see it signals to various path ways. Two of them appear to be particularly relevant. The classical, that is necessary for al analgysia. So the g protein is the one associated with analgesia and side effects. What pharmaceuticals are doing is developing medication thats do not engage the beta resting pathway with the notion that this medications will be useful for Pain Management without producing overdoses or without producing addiction. And research is underway and phase ii Clinical Trials are actually being down in one of those compounds. For overdoses, we work what is the issue completely to save them. The more widely available the drugs, are the greater the likelihood of success. Now with fentanyl and carfentanyl were finding that actually thnaloxone cannot revee these patients and they need higher doses. Its almost impossible to actually resuscitate them because they die actually as they are injecting the drug. Fentanyl and the other drugs get into the brain so rapidly. And more importantly, the patients who are resuscitated overdose again and eventually die. We have to treat them so we can protect them from future overdoses. Finally, medication. We have multiple treatment medications. Each of them different characteristics. Methadone, bupronophrine and vivitrol antagonist. Depending on what characteristics, can you use one medication or the other. Very useful. They prevent overdoses and relapses and Infectious Diseases but theyre not being used. And actually, less than 15 of individuals in the United States that could benefit from a medication are getting it. Multiple reasons why that is the case including stigma but also lack of infrastructure. So weve been working with the Health Care System in order to engage physicians on the proper treatment of opioid use disorders to see it as part of their responsibilities as physicians. Developing medications, alternative medications that improve compliance. Partnership that we did with the pharmaceutical that results Administration Every six months which would facilitate the compliance of the patients that are addicted to this opioid medications. And finally, with science, of course, we look at transformation. So an area were exploring for not just heroin but now for fentanyl as well as cocaine and nicotine is the development of vaccines, vaccines just using the same strategy we use for other vaccines that will develop antibodies from the drugs to when the person takes the drugs the antibodies biend to i and interfere with its transmission to the brain. This will be useful for preventing overdoses and, of course, for treating those that are addicted and perhaps into the future for prevention. And with that, i want to advertise some of the document thats we get if youre interested on any information regarding our research programs. And again, i want to thank you for your attention. Thanks, very much. Thank you, dr. Volkow. This has not been a real cheerful session. But i note that a lot of you are interested. There is a very high attendance. Im hoping our next speaker gives us a little cause to walk out of here with a little bit of hope. Our speaker is Karen Drexler. She is the National Mental Health Program director for addictive disorders and Veterans Administration. And who should know more about misuse of drugs than the Veterans Administration . Dr. Drexler is certified in both psychiatry and in addiction medicine and she is going to talk to us about treatments. Thank you so much. Im very honored to be here. Thank you to aaas and the Data Foundation for this invitation. And im delighted to give you a third perspective tonight. I am as debra said an addiction psychiatrist. I still practice at the Atlanta Va Medical Center where i practiced for most of the last 25 years. And i also for the last three years, though, have been working for Va Central Office here in washington, d. C. Doing Addiction Treatment policy and having the opportunity to be a consumer of science on two levels. Both as an individual practitioner but also as someone trying to translate the science to improve the health care of a population. So im employed full time by the department of Veterans Affairs and i have no commercial financial conflicts of interest. And tonight what id like to do is talk about i dont have to talk about opioid use disorder because dr. Volkow has done such a fantastic job of that. And ill mention as the doctor also spoke about how opioid use Disorder Treatment really begins with prevention and how we used the science to inform our policies about that. And then also how effective opioid use Disorder Treatment from i think a little bit more of the art of medicine. We apply with the science has shown us in a way thats patient centered and collaborative when were working at our best. I want to use this example. This is patient of mine about ten years ago. I share her story. She is a veteran but because this could be any one of us. Shes a very hardworking, licensed professional nurse. Practical nurse. Who was referred for Substance Use Disorder Treatment after an overdose. This is the culmination of 30 years of experience with prescription opioids and other controlled substances. She injured her back at age 24 and treated briefly with opioid pain medicine. She had a series of reinjuries and surgeries and ultimately ended up being treated with both opioids and muscle relaxants and multiple providers as her tolerance 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, i shared the dsm v for prescription opioid abuse disorder. If a person is frz taking them as prescribed, we dont include the increasing tolerance or the withdrawal symptoms as criteria for making a disorder diagnosis. But she really had most of these symptoms. She had craving or strong desire to use opioids. She was using in situations when it was hazardous, when she was really too intoxicated to drive. She was using larger amounts than she intended. And she had difficulty cutting down. She was spending a lot of time figuring out how to get the next dose of opioids and continued to use despite knowing that opioids were causing major problems. In fact after the overdose her primary care provider said i will not prescribe opioids for you unless you go to the Substance Abuse treatment program. And thats why she saw me. I was the gatekeeper for her next prescription of opioids she was hoping to obtain. So as both previous speakers have talked about, since the 1990s, opioid pain prescriptions have increased. But we really have not seen any change in americans reports of pain. However, the Overdose Deaths have increased dramatically. And as have the number of people who have developed opioid use disorder. Those intertwining epidemics. And this just my slide. Those of who you are epidemiologists in the audience may recognize this is a map of london in the 1800s. Showing cases of cholera that dr. John snow traced to the broad street water pump. And the solution was to take the handle off the pump. And had a tremendous effect on the cholera epidemic. I think this slide that weve already seen some versions of this where the kilograms of opioids sold went up, so did the deaths of opioid overdose and the admissions for opioid use disorder. There is our map of london for the Opioid Epidemic. And one important intervention as has already been discussed is to take the handle off the pump and to reduce the number of prescriptions for opioid pain medicines. So the centers for Disease Control and prevention has developed an evidence based guideline in which they recognize that nonopioid therapy is preferred for chronic pain for the reasons that dr. Volkow mentioned. When using opioids to use the lowest effective dose for the shortest period of time and to exercise caution and monitor closely. In the department of Veterans Affairs, we partner with the department of defense to create our own clinical practice guidelines. We have them for many medical conditions. And we use as the cdc did the grade methodology which takes into account four domains including the balance of desirable and undesirable outcomes and our confidence in the quality 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 for these guidelines we looked to at least observational studies that show some control element. And best of all randomized controlled Clinical Trials are even better analysis in multiple Clinical Trials. Based on these we came up with 18 evidence based recommendations to our practitioners. Im highlighting four of them here. We recommend alternatives to opioid therapy such as self management strategies, exercise, tai chi, and when other nonpharmacy treatments when theyre used, nonopioids, nonsteroidal drugs, receiving the longterm therapy, online such as drug Monitoring Programs to make sure that were not double prescribing. And monitoring for overdose potential and suicidality, and providing overdose education to our patients prescribing other drugs and making it as widely available as possible and assessing for suicide risk and intervening when necessary. Finally, as did the cdc, we recommend monitoring patient whos have chronic pain for the develop ment of opioid use disorder and whether we find it providing medication assisted treatment. So in va, in order to take the handle off the pump, we have been reducing opioid prescribing through our opioid safety initiative. This has been an education for providers as well as some metrics for Quality Improvement that we have disseminated throughout our system. We have seen some improvements. A 33 reduction since 2012 in opioids over time. It has been reduce bid 39 . And the veterans on long term and the veterans on longterm drugs with a urine screen has decreased. We are communicating with Prescription Drug Monitoring Programs in all but five of the states which is a tremendous technical feat because not every state Prescription Drug Monitoring Program uses the same software and they dont necessarily communicate with each other or with us. But i have to give credit to my colleagues in pharmacy benefits management and in i. T. For overcoming many hurdles to get to this point. We have seen these slides before so i wont go into much detail. The va is not alone. Nationally weve been making progress and yet Overdose Deaths have continued. This is a complicated picture that the doctor helped discern for us of intertwined epidemics. But as dr. Volkow also pointed out, patients who are prescribed oipd long term are at greatly increased risk for developing heroin addiction. Term are at risk for developing heroin addiction. So lets get back to my patient, the nurse. When her physical told her no more prescriptions, she turned to the elicit market and when she came to me for treatment, i talked with her about other drugs. Now i explained to her the mechanism of action and took this approach which were advocating system wide that patient treatment for opioid abuse disorder should be patientcentered and evidence based. It should be Life Sustaining and empowering the patient to be a partner in their care. Not a passive recipient of care. And it also needs to be accessible to those who need i it. So for patients centered care, it begins with shared decision making. The patient is the expert on his or her life. Hopefully we clinicians are experts on the entire menu of Treatment Options and we provide that information in a way thats easy to understand. And my colleagues in the va and our academic detailing service have created some education materials that make it easy to convey the rationale for medical assisted treatment. Opioid therapy is a particular kind that includes both bupronorphrine and it reduces hiv risky behavior, criminal behavior, cravings and withdrawal and importantly, opioid use. And as dr. Volkow also showed, methadone is a full activist and then buponorphrine is not. Then there is the full antagonist. Im able to provide this information. Buprenorphine is more readily available. You dont have to pick it up every day and take it in the clinic. It is fda approved. It improves treatment retention. It reduces mortality and it is recommended for most patients except those who have an anticipated need for opioid pain medicine. So i talked with my patient about how some patients find that actually getting on buprenorphine helps improve the pain. We also discussed one other option which is the extended release injectable which will block the mu opioid receptors and any opioids for pain and she elected not to take that one. So i wanted to also mention that its not just the medication alone but also medical management. This is what we called it in our clinical practice guidelines. There are several Research Studies showing this approach that relatively brief counseling but close monitoring by the clinician including drug testing, asking the patient about their use, asking about consequences and potentially using a measurementbased tool like the brief addiction monitor. Educating the patient about the opioid use disorder consequences and treatments connecting the dots, if you will, and encouraging them to abstain to attend mutual help groups in the community and to make important lifestyle changes. Now my particular patient was also attending at a lot of groups and classes and she was learning at a rapid pace, different skills to support her. And she elected to take buprenorphine. Because of her pain, her chronic pain, i suggested she split the dose and take it twice a day rather than once a day. And she completed our intensive outpatient program. But really within a week of starting this medication, she was so engaged and learning so much. She started exercise. She started being active in 12 Step Recovery groups. And then i transferred her to a continuing care group because of our system i work in the intensive phase. So she had graduated and moved on to a less intensive phase. But she kept coming back at every opportunity stopping by my office and saying, dr. Drexler, that was the best medication i cant tell you. And telling me about another person that she knew back when and that she saw and encouraged to come and find treatment. It really turned her life around. And she remained in recovery on medication for years. She moved on and she keeps dropping in every once in a while to let me know how shes doing. So i want to raise this issue that dr. Volkov raised. Our treatment for Substance Use disorders is episodic, as if we were treating a case of pneumonia. And once we finish a 28day in patient intensive program we would be cured for the rest of our lives. But these are really more chronic illnesses that would benefit most from the long view, from a chronic disease management model. So this is something that were taking the synthesis of the evidence and suggesting this model moving forward. This is really a work in progress. We havent implemented it yet. But were promoting self management. We have good evidence that participating in group mutual help like narcotics anonymous or Alcoholics Anonymous can be helpful. Teaching coping skills that folks can use to cope with pain or to help to get to sleep without using medications. And then disseminating out the evidence based treatment into General Health care settings wherever the patients are presenting and primary care and pain medicine, in hepatitis clinics. And then also keeping infrastructure for managing those most complex patients. Now this slide apologize. I know you probably cant see the graph. What id like to point out on the graph is that the medication assisted treatment with buprenorphine and methadone both reduced mortality for those with opioid use disorder and its not just overdose mortality. Its all cause mortality. So what are our challenges and next steps of getting this life saving treatment to those who need it . Dr. Volkow alluded to this earlier, among privately insured patients hospitalized for opioid abuse disorder only 17 received medication following their hospitalization. Can you imagine if we treated diabetes the same way . 54 received some Psycho Social Services following hospitalization. But 40 received no continuing care. According to others, in 2013, 27 of treatment plans for heroin use disorder in s. U. D. Speciality clinics included medicationassisted treatment. We have a long way to go. And patients in the va center, 34 received medication in fiscal year 2016. So we can anticipate that demand for opioid use Disorder Treatment is going to continue to increase. And our next steps are challenging on how to disseminate the evidence based practices widely so theyre available. So as i mentioned the good news is we have even as demand has been increasing, some of the efforts weve made to educate providers and to support them with consultation and education have increased our proscribing. And then id like to just present to you four evidence based models that we might follow. One is brief counseling is sufficient for many patients with opioid use disorder. 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 receive that with an additional hour of counseling. All of the patients received buprenorphine. They had some Pretty Amazing results. Almost 80 retention in treatment at 12 weeks. And four to five weeks of continuous consecutive abstinence but that additional hour of cognitive behavioral therapy, which we know is helpful, really didnt make a difference as long as the medication was prescribed with close monitoring and that brief counseling by the prescriber. So i think thats an opportunity to disseminate this more widely. This is from the nida Clinical Trials network that similarly disseminated out a very similar model to general Mental Health care settings. What they found was that while patients were engaged in treatment on the buprenorphine, their chances of remaining sober were ten times greater than after it was tapered off at the end of the trial. And this is the socalled massachusetts model of nurse Care Management by dan alfred, colleen mabell and other colleagues in which theyve taken the model and instead of the physician or the prescriber doing the brief counseling, trained nurse care managers to do the brief counseling and the close followup. And they work within a team with a clinical pharmacist and counsellor as well. And they have been able through that model to dramatically increase the number of patients receiving buprenorphine. And then another similar but different model in the state of new mexico as you saw was heavy hit early on in the opioid crisis, the state of new mexico realized they needed to disseminate medication assisted treatment out to rural areas quickly and they developed a model using a telehealth hub in which providers and primary care clinics in rural new mexico had a weekly meeting basically clinical rounds like you might have done in medical school and residency only done virtually using telehealth and with that consultation and training, they were able to dramatically increase the availability of medicationassisted treatment. And then finally ill mention this one model thats from the alcohol literature. This is dave oslin and colleagues in the va who randomized patients to receive alcohol Care Management, again with care managers supporting the primary care docs. As the primary care docs prescribe naltrexone and they found those who were randomized to receive that care and primary care not only were they better engaged in treatment because they didnt have to pass from one clinic to another, but the percent of heavy drinking days also was superior to those who got treatment as usual. So im very hopeful that well be able to disseminate these models out and one key partner at least for us in the va is academic detailing. We use the same techniques that pharmaceutical Companies Use to promote new products to promote evidence based best practices. And this they helped partner with our overdose education distribution. And this is just a graph that since 2014 when we started this we have actually dispensed over 71,000 at this point its over 75,000 rescue kits. So potential next steps. I think there is a lot to be done in terms of implementation science. We have some actual treatment thats 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 that dr. Volkov talked with us about. And how we can enhance education. Right now in order to be able to prescribe buprenorphine, physicians have to take an eight hour training course. Nurse practitioners and pas have to 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 that eight or 24 hours of training in their basic curriculum . So thats one area where we could improve. We could also let folks in the field try these models. For implementing, like nurse care manager like the telehealth hub and spoke and learn from those and apply the Lessons Learned to continuously improve our processes. So opioid use disorder is treatable and preventable and we do need more help for newer, better treatments as well as how to implement the ones we have. Thank you. [ applause ] dan and nora, would you come up . Were going to take questions from the audience. But you need to line up there. There are microphones in the two aisles. When i call on you, please give your name and affiliation or status. I wanted to ask a question of 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 take drugs or using opioids . Lets stick with opioids . Okay. So there is an increased risk for chronic pain among the veterans. And i dont know off the top of my head about whether we prescribe opioids more for patients who have chronic pain in the general population. It does make sense that veterans have more chronic paint. Theyve had very physically demanding jobs. Very demanding. Jumping out of airplanes. My son did that. Dr. Volkow, why is it that some people can have, for example, break a bone and have surgery and be prescribed an opioid and take it for a period of time and some people become addicted and other people just quit taking it . Well, were all built differently. One of the things we have come to recognize not just for opioids but for any drugs is that there are some people who are more vulnerable to become addicted than others. So what, of course, physicians always want to know is can you give me a test that can let me know if someone if im going to prescribe them on opioid are they going to be at higher risk or not . We know that a lot of that vulnerability is genetic. We dont have a genetic test right now that can help us. But there are many things that we can actually ask patient thats can give us an idea of their risk. One of them, have they been addicted in the past to drugs . If they had a prior history of addiction whether tobacco or alcohol or certainly opioids should alert the physician that theyre at high risk. The younger you are, the greater the risk you may have of becoming addicted. This is one of the reasons in general, opioid medications should not be prescribed to teenagers unless they are necessary. And so and, too, Family History also is a factor that contributes to that. Mental illnesses can increase your risk for becoming addicted to drugs. Theyre actually many things that can make you feel better and that leads you to actually seek them out in order to also medicate themselves. But at the end of the day, there is no test that can guarantee that you a patient is not going become addicted. There are factors that tell you someone is a greater risk. So if someone is going to be prescribed opioids repeatedly, just as it is described in the cdc guidelines, its required that they be monitored very, very carefully. That every time that prescription is going to be renewed that the physician evaluate to ensure there is not any development of misuse of opioids or addiction. Thank you. Dan . Yes . I wanted to refer to your graph that showed the heroin users on the left side, the younger users. Are they just switching over . Are they just people who are switching from they would have been cocaine addicts or Something Else years ago but now heroin is the in drug or its less expensive or Something Like that . Are these atrakting new people who would never have been addicted to another substance. Just like the previous question. The answer is complex. Epidemics can have a sort of wave effect that just sweeps in people and increases the size of the vulnerable population, we tested the size of the vulnerable population by excessively prime opioid pills. What i would like to answer your question with is an anecdote. Sorry. And that is in my observations my team and i have been to little towns out side of boston, lawrence, baltimore, chicago, West Virginia, we see a lot of new people out there. And new people arent necessarily coming from prescription pills anymore. Theres a new wave that are coming in there. Theyre young. And im not sure whether they would have done another drug if heroin wasnt the thing now. But i do know that there is a mixed picture right now. There is a cultural wave, another an anecdote, for example, i met a 29yearold out side of a small town in West Virginia, nice guy. Works and just also happens to have a daily heroin habit. And he went back to his ten Year High School reunion, small town. Everyone knows everyones business. Everyone knows who left, who stayed, who lived, who died . Half half his High School Class is gone. The first time in 17 years i almost had to stop an interview because i had a very emotional response to that. Pills and alcohol pills and heroin. One or two Motor Vehicle or industrial accidents but mostly pills and heroin. There is something very large out there happening right now. There is no easy answer to. Yeah. Okay. Lets take some questions. Go ahead. Thank you. My name is ashby sharp, chief of ethics policy at the Veterans Health administration. I just want to add a dimension to the doctors excellent presentation that one of the things that we did in our policy on long term opioid use was to prohibit the use of pain contracts because from an ethics perspective, we felt they were unenforceable and instead we substituted a robust and informed consent process. So that patients get education and a good conversation about the risks, benefits and alternatives to long term opioid use. But the two questions i have are actually about integrating policy strategies. So Patient Satisfaction surveys, ive heard from clinical providers outside of va that they feel pressured to prescribe all drugs but in particular able geezics and opioids in order for patients to give them a positive satisfaction rating because theyre going to be judged on that. And the seconds was what about Third Party Insurance coverage for opioid use treatment and what can be done to encourage other players in the market to get on to this initiative. Dr. Drexler, do you want to take that . Ill take the first one. Im not an expert in third party care. I dont think any of you are probably. Having been in the va. But i am on the steep end of the learning curve about unintended consequences of policies. And my thought about it is its a little like safety and efficacy trials in medical development. You do phase i in safety and healthy individuals. Phase ii, safety and individuals that are affected. Phase iii, the randomized Clinical Trials. And if theyre positive and encouraging then you roll it out and you monitor to see what happens out in the real world. A third of the adverse events we hear about, we learn after market, after the fda approved. We do the same with policy. We do our best as you saw to create policy based on the science of what seems like it will work. But when you roll it out in the real world, you dont know whats going to happen. I think its very important that we keep monitoring in the same way we try to monitor when we rollout a new drug to see if the new policies are having the intended effect or if there something we couldnt anticipate. And then make course corrections as we need to. Im just going to comment on the second question. Its actually not that im an exert on insurance but i read a lot about the issue of opioid medications and the use for chronic Pain Management and i get emails from physicians that are experts on pain and say we completely agree with you with the recommendations of not using opioids as the first line of treatment which is what the cdc guidelines are saying, the problem is that we have is that not all of the insurances actually cover for it and in the paperwork that is required in order to justify some of the alternative treatments which are considered first line of treatment for some of these pain conditions are not accepted by the insurance. The insurance. So as a result of that, the physicians can not do the right thing because its nor cheaper to prescribe an opioid medication. So one of the things that is clear is, yes, we need to educate physicians of proper management of pain and proper use of Prescription Medications but we need do structural changes into our Health Care System such that the proper treatments are covered by the insurance. Because otherwise they can you write all of the guidelines that you want if someone is not going to reimburse the patient, theyre not going to be given that intervention. So that is an aspect that we need to also be very aware of. That we generated a system that has the facilitation of opioid use over other interventions. In the past, the governments of china have not been cracking down on the suppliers of sin thicket opioids, but is there any evidence now that the opioid addiction of any sort is not spreading in china, itself. And might that lead the government to the become more serious . Well, i dont have any evidence for that. I nknow that stimulants are ver popular used and abused in southeast asia, but not necessa necessarily in synthetic opioids. There is high level agreements to restrict a number of fentanyl and a number of the cousins fromming being produ from bei and produced in china. But i would have to say that my own personal opinion on that is fairly cynical, and im not sure how one effectively controls the tiniest fraction of, of the e lis it is production in the country with enormous industrial capacity. I am not sure howen with the laws and the regulations prohibiting the production and how they are actually going to pull it off. But it is china. Maybe they will. I mean, i want, i want the supply control to happen. I do. But it a has not worked effectively for drugs like c cocaine and heroin in countries who have a lot less pull in the world than china does now. And i was in china last year, and we were trying to actually create new models for treatment of patients who have a heroin and they have of course, a very severe problem with the heroin abuse, but they have been successful in implementing in clinic clinics, but i was particularly interested like you on that exact question. Are they seeing the consequences of this growth of opioids and so i met with the director cdc and i asked him if he is starting to see the increase in the number of overdoses pointing to us the fact that you are lacing heroin with fentanyl, and he did not know about it. So i mean, but again, i think that the issue, it is a different country, and they have a abilities of implementing intervention much faster a than the hospital. And the other one, i do not know the extent to which there is a accurate knowledge of the problem. I dont nt know if it is relati ease, and so i was surprised. From this side. Hi. Edded billski, and researcher and medical educator. We are doing a better job at the university to do have a better professional approach, but it is disheartening that 17 of the properly insured are getting the treatments that we dont have at least some effectiveness, and then you are starting to look at the more rural populations, atrisk, and underserved medical communities and those numbers are probably more strikingly against us. Taking it taking it a step further, and thinking of the demand for the opioid, and the opioid connections with the social bonding for example, and what is going on in our society, and how and true will we address the more fundamental things that drive people to take a variety of different substances or do certain behaviors that harm them, and also the community. Who is going to take response foblter that . D responsibility for that . Dan, would you like to take responsibility for that . I will start. And two two halves of the comment. And the first part is that i think that we either have or will have a severe labor shortage in Substance Abuse treatment. Theres simply not enough p providers and the providers are not distributed in a way that meet the problem. I just have West Virginia in my head right now. So promoting the medical education, and through school, and medical rez dsidency could help, and also what would help is incentive programs whether it is payment to promote a generation moving into psychiatry or treatment of Mental Health. And so also, i am writing a paper with a couple of colleagues looking at what are the deeper root issues of this, because, because i agree with the line that we are saying that excessive prescribing led to the wave. I like that we have to take the handle off of the water pump, but there was a reason why this epidemic settled in the areas that it has settled into. Right there. Is a mi yachl going on, and multiple culpability that says something about this segment of society, and whether it is poverty, disenfranchisement or lack of future or opportunity or hope, and some what they call the diseases of despair lining up in appalachian, and up through the midwest and over to eastward. And that is a little more complex. And thank you for bringing it up and i feel a little sense of despair as well, and hopelessness, but going back to the slide where we did turn that epidemic around. And so we have the evidence a the tools and the ideas and we need resources, and creative ways to take the resources to apply them into the regions, and telemedicine to get them into the areas that might be access to the approaches to get to that like telemedicine. So this particular specific epidemic, we can turn it around and the fault problem, i am not so sure. And i would like to reiterate that, because in many way, i would like to end up in a very positive way, and i look at it from the perspective of what is the challenge that we have on addressing the Opioid Epidemic, and we know how to do it, and if we have a road map, we will implement and succeed. I always put in the counter argument if someone were to tell me how the address the problem of the alzheimers, i would not know how the start. We dont have treatments, and we dont know how to properly prevent it, but here, we have a much better understanding, and we know where the epidemic generated and we now ho to grow it, and prevent it, and treat it, but it does require a very integrated approach of resources to do it. And look at tobacco. We can do it, but obviously, it is going to require an investment. And another thing that is important that we have not been discussing, but we have a 20th century treatment of disorders which is fantastic. We have never seen anything like that, but we want to be sure that funding going to go for evidence based treatment, and for call quality care which is not something that we speak much about in terms of the disorders, and we speak about the quality care on cancer, but not here. We need to demand that actually, and we need to demand and use it as a way to improvinging the quality of care for people suffering from the opioid disorders and any other addiction. Thank you. I will take this one, and then that, and then we will will adjourn and go on to enjoy the reception. From the health care field, and im also a veteran, and so in relation to the v. A. , can you talk about what has bn de bee i denigraded. And so as veterans are going in and out of Health Care Systems, can you tell us how to address the impact. And also, some other questions specifically for the other members of the panel. You have been mentioning heroin, but from the sta tix ining statistics of 2016, and talking about elicit drugs for sorry, 2015, marijuana at 2. 6 million, and pain relievers in general 2. 1 million and cocaine 9688,000, and mda is 96,000, and am fet means at 225,000, and heroin is low at 135,000. I am wondering how you are mentioning that slightly, you touched upon it in the last slide, sir, of separating the heroin problem from the overall pain reliever, and so it appears that heroin is low on the scale, and conflating the operation, and doing a disservice, and i would love for you to touch upon that, thank you. May i a take the first question first . We will be brief in the questions and answers. All right. So, i will be as succinct as possible, a i would like to thank you for the service, and ask you the please google the department of the va, and we are a huge organization, and we do have a transition care program, Care Management so that veterans who are leavinging the d. O. D. Can engage in the employment opportunities, and please reach out for us so we can help you. And specifically more than [ inaudible ]. Okay. The doctor will probably want to weigh in, but thank you for bringing up the fact that this is one piece of the much larger issue about American Society there. Are other drugs of misuse and abuse, and some of which are very common. Marijuana is very common, and marijuana is not deadly. Heroin just happens to be dead the deadliar than the more common dr drug, and one of the legal drugs that is deadliest isle alcohol. So we have to constantly remind ourselves thate alcohol. So we have to constantly remind ourselves th alcohol. So we have to constantly remind ourselves that working with teens and vulnerable populations of what is recreational alcohol use, because people are testing the genetics, and alcohol is a highly genetic predisposition, and people should know the family histories and magnify the resilience factors to not progress. I happy to know heroin well, and that is why aim going to the emphasize it, and we are in a death wave with heroin and we need to address it or there will be segments of the country where we will lose a piece of a generation. Can we go over here now . I will try to keep it very brief, but thinking about what you said about losing segments of generations, and comments previously about diseases of despair. I am wondering if there is any research on the overlap of the of doses that may also be suicides and thinking of suicide as a major Public Health crisis right now . Do we know anything of what research is being done, and how do we separate that which can be treated by Substance Use treatment, and also those who may require more specific Suicide Prevention intervention. That is an important question, and indeed, we dont know what the numbers are. And so from those 33,000 deaths of opioids, it is possible, and i think that i wouldnt be completely off of the mark that 15 of them are relate d to suicides, and we know that the loss in years in rms the of the life span expectancy in the United States that we are seeing in middle age, white people is related not just to the overdose, and also to the significant increases that we are seeing in the suicide. So we also know that in individuals who suffer from depression, if they are taking opioids, their risk for suicide is much higher. So there is a very strong morbidity between both of them, and indeed, one of the things that the cdc guidelines tells you is that among the factors associated with the higher risk of overdose is having a history of depression. Because if you are depressed and they prescribe you an opioid, your risk for suicide in particular if you are a woman of like 8 or 10fold higher, and so it is a huge effect. In many of the cases of the of dose doses, we are seeing the intentional overdose, and no way to distinguish one from another. And well, this is not the most cheerful of events that we have held with the Dana Foundation, but i actually do think it is one of the most topical, and important. The larnl sige size of the audi attests to that. And before we go to the reception, i would like to thank the Dana Foundation for all that they have done. Will [ applause ] and also to thank the terrific speakers. [ applause ] thank you. Former cia director john brennan is on capitol hill for a house intelligence committee, and he is going to be looking into the investigation of russian influence into the 2016 president ial campaign, and that is going to be live tuesday at 10 00 a. M. Here on cspan. And also, there will be a visa overstays and National Security coverage with the House Homeland Security subcommittee that will be underway at 2 00 p. M. Eastern and also live here on cspan3. Never let anyone define you. That is the first lesson that i want to leave you with. Only you define who you are. Only you. Our hearts should be open, not to falling in love, but to the world. We need to look. We need to care. And we need to contribute. Dont ever let anyone tell you that your dreams are silly. And if you have to look back on your life, regret the things that you did and not what you didnt do. Nothing stays still. Things will change. The question for you is whether and how you will participate in the process of creative change. Just a few past commencement speeches from the cspan video library. Watch more of this years commencement speeches on saturday, may 27th, may 29th, memorial day, and june 3rd on cspan, earlier this month, the Veterans Affairs secretary David Shulkin was asked about operations at his department while testifying on capitol hill. He spoke about efforts to reduce wait times for veterans seeking case, and ongoing attempts to improve the i. T
comparemela.com © 2020. All Rights Reserved.