SEAside, July 12, 2018: The Prescription Drug and Heroin Epidemic A Public Health Response

SEAside, July 12, 2018: The Prescription Drug and Heroin Epidemic A Public Health Response


TEST. TEST. TEST. TEST. TEST. TEST. TEST. ALL RIGHT. SO IT’S 2:00. HELLO AND WELCOME TO TODAY’S SEA SIDE WEBINAR. I’M THE DATA AND EVALUATION COORDINATOR FOR THE SOUTHEASTERN ATLANTIC REGION. BEFORE WE BEGIN WITH THE GUEST SPEAKER THERE’S ADMINISTRATOR THINGS I’LL RUN BY. IF YOU’D LIKE TO SHARE ACTIVITIES YOU’VE DONE OR RESOURCES YOU’VE UTILIZED RELATED TO THE OPIOID EPIDEMIC FEEL FREE TO ENTER THOSE IN THE CHAT BOX. AS YOU’RE SHARING, COMMUNITYING AND ASKING QUESTIONS IN THE CHAT BOX, PLEASE BE SURE TO SEND TO ALL ATTENDEES SO OUR GUEST PRESENTER, COLLEAGUES AND I CAN ALL SEE YOUR QUESTION OR ANY INFORMATION THAT YOU SHARED. IF YOU NEED CLOSED CAPTIONING FOR TODAY’S WEBINAR I’LL POST THE LINK IN THE CHAT BOX FOR YOU RIGHT NOW. THE WEBINAR IS LABELLED A SEA SIDE WEBINAR THE PRESCRIPTION DRUG AND HEROIN EPIDEMIC AND WE HAVE THE PRESENTER AN ASSOCIATE PROFESSOR IN THE DEPARTMENT OF PSYCHOLOGICAL SCIENCES. HIS RESEARCH INTERESTS HAVE BEEN FOCUSSED ON EVIDENCE BASED PRACTICES PRIMARILY IN SUBSTANCE ABUSE. HE’S THE PRINCIPLE INVESTIGATOR ON A TRAINING GRANT ON THE SUBSTANCE ABUSE AND TRAINING HEALTH ADMINISTRATION TO PROVIDE TRAINING ON ALCOHOL AND DRUGS SCREENING BRIEF INTERVENTION AND REFERRAL TO TREATMENT, HEALTH PROFESSIONAL STUDENTS ACROSS THE AUGUSTA UNIVERSITY CAMPUS AND RE-ENTER PROGRAM TO INITIATE SUBSTANCE TREATMENT SERVICES FOR INCARCERATED PERSONS AND COMMUNITY-BASED TREATMENT UPON RELEASE AND HEALTH LITERACY GRANT FROM THE LIBRARY OF MEDICINE FOCUSSED ON INCARCERATED POPULATIONS. HIS WORK HAS BEEN [INDISCERNIBLE] BY A NUMBER OF STATE AGENCY AND FOUNDATIONS AND HAS BEEN WIDELY PUBLISHED. EVERYONE PLEASE WELCOME AARON.>>THANK YOU, AMY. I APPRECIATE THE INTRODUCTION. I’LL DIVE RIGHT INTO THE PROPOSAL OR INVESTIGATION AND IF WE ALL HAVE QUESTIONS AS WE GO THROUGH THE PRESENTATION FEEL FREE TO PUT THOSE IN THE CHAT BOX AND WE’LL SYMPTOM AND ADDRESS THOSE QUESTIONS AS AS WELL AS WE CAN. LET’S MOVE THROUGH THE FIRST SLIDE HERE. ONE OF THE THINGS YOU’VE PROBABLY SEEN A LOT IN THE NEWS OVER THE PAST TWO OR THREE YEARS HAS BEEN HEADLINES SUCH AS THE ONES WE SEE HERE. SENSATIONAL HEADLINES BEFORE THE PRESCRIPTION DRUG EPIDEMIC AND THE NUMBER OF PEOPLE AFFECTED BY THE PRESCRIPTION DRUG AND HEROIN EPIDEMIC AND YOU MAY HAVE SEEN GRAPHIC PICTURES ASSOCIATE WITH THE HEROIN EPIDEMIC. THE ONE UP IN THE TOP LEFT CORNER IN PARTICULAR REALLY WAS CIRCULATED WIDESPREAD AND WHAT YOU SEE THERE ARE TWO PARENTS WHO HAVE OVERDOSED WHILE DRIVING THEIR CAR AND THEIR TODDLER IN THE BACKSEAT STRAPPED IN WONDERING WHAT’S GOING ON. NOT UNCOMMON AT ALL TO SEE THESE TYPES OF PHOTOS IN THE NEWS. AND THERE’S BEEN A NUMBER OF CELEBRITIES. FOR EXAMPLE, PRINCE OVERDOSED ON FENTANYL AND [INDISCERNIBLE] OVERDOSED IN A NEW YORK APARTMENT OF AN OVERDOSE OF DRUGS, LIKELY HEROIN. MORE RECENTLY TOM PETTY IN JANUARY OF THIS PAST YEAR DIED OF AN ACCIDENTAL OVERDOSE AND SOME TYPE OF OPIOID. HEATH LEDGER DIED OF AN OVERDOSE THREE YEARS AGO I THINK. AND TIGER WOODS WAS ARRESTED FOR A DUI A LITTLE OVER A YEAR AGO AND WENT INTO A DRUG TREATMENT PROGRAM TO OVERCOME HIS DRUG ISSUE. SO JUST AN OUTLINE FOR TODAY. THESE ARE THE TYPES OF THINGS THAT I’D LIKE TO COVER WITH YOU OVER THE COURSE OF THE NEXT 50 MINUTES OR SO. AND THERE’S THINGS ASSOCIATE WITH THE OPIOID CRISIS. WE’LL LOOK AT THE EPIDEMIOLOGY OF THE EPIDEMIC AND NATIONAL DATA AND HOW THE CRISIS VARIES ACROSS REGIONS AND STATES. AND A LITTLE HISTORY ON HOW WE MANAGE TO GET INTO THE PROBLEM THAT WE’RE CURRENTLY FACING AND FINALLY A FEW SLIDES ON HOW TO GO ABOUT ADDRESSING THE EPIDEMIC FROM A PUBLIC HEALTH APPROACH INCLUDING PREVENTION AND TREATMENT AND NALOXONE SOME MAY HAVE HEARD ABOUT BUT I’LL EXPLAIN MORE WHEN WE GET TO THAT PART OF THE PRESENTATION. AND UNFORTUNATELY, WE’LL LOOK AT THE REALITY OF THE WORLD WE LIVE IN AND HOW DIFFICULT IT’S GOING TO BE TO ADDRESS THIS PROBLEM. OPIATE REFERS TO NATURAL SUBSTANCES DERIVED FROM OPIUM, MORPHINE AND CODEINE. THE WORDS OPIOIDS DO NOT OCCUR NATURALLY BUT THERE COULD BE SEMI-SYNTHETIC OPIOIDS WHICH ARE HYBRIDS OF OPIOIDS WITH HEROIN AND HYDROCODONE AND OXYCODONE AND FULLY SYNTHETIC OPIOIDS WHICH ARE CHEMICALLY MANUFACTURED AND THAT INCLUDES FENTANYL AND CARFENTANIL WHICH IS AN INTERESTING DRUG 10,000 TIMES MORE POTENT THAN MORPHINE. THE REALITY IS OPIATES HAVE BEEN AROUND AND USED TO CONTROL PAIN THOUSANDS OF YEAR AND DATE AS FAR AS BACK AS 3400B.C. AND WE’LL LOOK AT THAT IN MORE DETAIL WHEN WE LOOK AT THE HISTORY IN A COUPLE MINUTES. AND THERE’S THE HIGHEST RATE OF THE DARKEST COLORED COUNTIES ARE IN THE APPALACHIAN AND MOVING TO SOUTHERN NEVADA AND NORTHWESTERN ARIZONA. THE STRIKING THING ABOUT THIS TO ME IS WHAT THOSE DARK COLORS MEAN. IT’S GREATER THAN PRESCRIPTION PER 100 PERSONS. THAT MEANS WITHIN THE COUNTIES THERE’S MORE THAN ONE PRESCRIPTION PER PERSON PER YEAR IN THOSE COUNTIES WHICH IS JUST BAFFLING TO ME. THE REALITY IS THE U.S. COMPRISES OF LESS THAN 5% OF THE WORLD’S POPULATION BUT CONSUMES 80% OF THE GLOBAL OPIOID SUPPLY AND TWO-THIRDS OF THE WORLD’S LEGAL DRUGS AS WELL. IF YOU LOOK AT THE CHART TO THE RIGHT OF THAT HEADLINE YOU’LL SEE THE TOP FIVE OPIOID COUNTRIES AND THE U.S. IS FAR ABOVE ALL THE OTHERS ABOVE CANADA AND GERMANY AND DENMARK AND AUSTRIA HAVING A CONSUMPTION RATE HALF THE U.S. RATE. HERE’S A HEADLINE FROM DECEMBER OF LAST YEAR THE OPIOID USE IS SO BAD IT’S STARTING TO LOWER OUR LIFE EXPECTANCY. FOR WHATEVER REASON IT HASN’T HIT OTHER COUNTRIES AS ITS HIT THE U.S. IN ADDITION TO THE OPIOID CRISIS THERE’S BEEN A CONCURRENT RISE IN HEROIN USE. THAT IS PRIMARILY COMING OUT OF MEXICO, THE JALISCO REGION TO BE EXACT. AND NOW WE HAVE SMALLER CARTELS OF YOUNG MEXICAN MEN THAT COME INTO THE COUNTRY, SET UP IN TOWNS THROUGHOUT THE U.S. STAY IN EXTENDED USE HOTELS AND BUY AN INEXPENSIVE CARS AND DELIVER HEROIN TO PEOPLE’S DOORS AS IF THEY’RE DELIVERING PIZZA. THIS MAKES IT PARTICULARLY DIFFICULT TO CONTROL BECAUSE AS SOON AS ONE MAN IS ARRESTED ESSENTIALLY ANOTHER ONE COMES IN FROM MEXICO TO TAKE THAT PERSON’S PLACE. SO THAT’S BEEN DIFFICULT TO GET A HANDLE ON OVER THE PAST FIVE TO 10 YEARS. THIS SAY MAP OF THE AND THIS IS THE ABUSE RATE. EARLIER IT SHOWED THE PRESCRIPTION RATES ACROSS THE COUNTRY AND YOU’LL SEE THE MAP OF OPIOID ABUSE RATES MATCHES THE PRESCRIPTION SO CONCENTRATED IN THE APPALACHIAN REGION OF THE COUNTRY AS WELL AS ALONG THE WEST COAST AND SOUTHERN NEVADA, NORTHWESTERN, ARIZONA. SO IT LOOKS VERY SIMILAR TO THE PRESCRIPTION RATES THAT WE SAW EARLIER. THE IMPACT IS THERE’S BEEN A HUGE SURGE IN DRUG RELATED OPIOID DEATHS IN 2016, THE LATEST DATA AVAILABLE, 64,000 AMERICANS DIED FROM DRUG OVERDOSES. WHAT YOU’LL SEE IF YOU LOOK AT THE CHART IS THAT THIS HAS EXPANDED AND GROWN TREMENDOUSLY OVER THE PAST 20 YEARS STARTING IN 1999 THERE WERE DEATHS IN 19 YEARS THE NATIONAL HAS MORE THAN TRIPLED. THE INTERESTING THING IS IT’S NOT BEEN DRIVEN BY THE SAME SUBSTANCE. WHAT YOU’LL SEE IS OVERDOSE DEATHS INVOLVING ANY OPIOID. THIS IS THE DEATHS PER 00,000 POPULATION. 100,000 POPULATION. YOU’LL SEE THE DEATHS WERE INITIALLY DRIVEN BY THE DARKER LINE WHICH IS THE PRESCRIPTION OPIOIDS. THAT LEVEL OFF IN 2011 AND REMAINED RELATIVELY FLAT THE PAST FIVE OR SIX YEARS BUT ESSENTIALLY WHAT STARTED TO TAKE OFF IN 2010 AND 2011 IS OVERDOSE DEATHS RELATE TO HEROIN AND OTHER SYNTHETIC OPIOIDS. THAT’S BEEN DRIVING THE OVERDOSE RELATED DEATH OVER THE PAST FIVE YEARS. THIS IS JUST THE AGE-ADJUSTED OVERDOSE DEATH BY STATE IN 2016 AND WHAT YOU’LL NOTICE SIMILAR TO THE PRESCRIPTION RATE AND OPIOIDS ABUSE DEATHS IS THEY’RE HEAVILY CONCENTRATED IN THE APPALACHIAN REGION OF THE U.S. AND MORE SO ALONG THE EAST COAST AND IN NEVADA, ARIZONA AND UTAH, NEW MEXICO AND ALONG THE WEST. IT CERTAINLY VARIES BY STATE AND REGIONS IN TERMS OF WHAT REGIONS HAVE BEEN MOST IMPACTED BY THE OVERDOSE DEATHS. GEORGIA, FORTUNATELY, WHERE I’M FROM HAS BEEN VERY FORTUNATE IN ALL OF THIS AND HAS NOT BEEN AS HEAVILY IMPACTED AS SOME OF THE OTHER STATES. SO THIS IS JUST A LOOK. YOU MAY LOOK QUICKLY AND SEE IF YOU SEE YOUR STATE IN THE TABLE. THIS IS A LOOK AT HOW THE OVERDOSE DEATH RATE HAS CHANGED BY STATE BETWEEN 2010 AND 2015. IF YOU LOOK AT THE OPEN CIRCLE THAT’S THE DEATH RATE IN 2010 AND THE DARK-COLORED CIRCLE IS THE RATE IN 2015. WHAT YOU’LL SEE IS UP AT THE TOP, THAT TENDS TO BE THE STATE MOST HEAVILY IMPACTED AND THOSE ARE HEAVILY CONCENTRATED IN THE APPALACHIAN REGION UP TO THE NORTHEAST NEW HAMPSHIRE AND MASSACHUSETTS. I HAVE AN ARROW POINTING TO GEORGIA AND THE INCREASE HAS BEEN MINIMAL. THE INTERESTING THING ABOUT THE EPIDEMIC IS IT’S TWO SEPARATE EPIDEMICS. THE RATE START TO FLATTEN IN 2011 AND OPIOID RELATED DEATHS START TO INCREASE ABOUT THE SAME TIME. ESSENTIALLY AS PRESCRIPTION OPIATES BECAME MORE DIFFICULT TO OBTAIN, PEOPLE START TO SWITCH TO HEROIN AND OTHER OPIATES. THE REALITY LOOKS DIFFERENT IF YOU LOOK AT THE OVERDOSE RATE IN THE U.S. BY AGE — WHILE SOME OF THAT WAS PROBABLY HAPPENING THERE WERE SOME PEOPLE WHO WERE NO LONGER TO GET PRESCRIPTION OPIOIDS EASILY AND SWITCHED TO HEROIN WHICH WAS EASIER TO OBTAIN AND IF YOU LOOK AT THE NEXT TWO SLIDES WHAT YOU’LL SEE IS THE DEMOGRAPHICS ARE DIFFERENT. SO THIS IS THE OPIOID OVERDOSE DEATH PRESCRIPTION IN THE U.S. BY AGE. YOU’LL SEE THE HIGHEST PRESCRIPTION OVERDOSE DEATH OVER THAT THREE-YEAR SPAN WAS IN THE 50 AND 65 YEAR AGE RANGE BUT IF YOU LOOK AT HEROIN OVERDOSE RANGE THOSE ARE VERY HEAVILY CONCENTRATED AMONG THE YOUNGER AGES SO THIS IS WHERE MOST THE PEOPLE WHO ARE PASSING AWAY OR OVERDOSING ON HEROIN ARE SIGNIFICANTLY YOUNGER. THE ISSUE OF FENTANYL IS AN IT’S 30 TO 40 TIMES STRONGER THAN HEROIN BY WEIGHT AND WHAT’S STARTING TO HAPPEN IS THAT FENTANYL IS STARTED TO BE ADD TO HEROIN TO PEOPLE DON’T REALIZE THE POTENCY. WE HAVE SEEN THIS EMERGE OVER THE PAST FOUR TO FIVE YEARS IT’S INCREASED 300% FROM LATE 2013 TO EARLY 2014 AND IT’S NOT THE PHARMACEUTICAL FENTANYL IT’S IMPORTED FROM CHINA AND PRIMARILY COMING INTO THE NORTHEASTERN U.S. WE’LL SEE THAT ON THE MAP HERE. THIS IS THE NUMBER OF DRUG PRODUCTS FOUND TO INCLUDE FENTANYL RELATIVELY MINOR IN THE U.S. IN 2015 AND THERE WERE DARKER COLORS, [INDISCERNIBLE] MORE STATES STARTED TO TURN DARKER COLORS. YOU CAN SEE THE FENTANYL SPREAD FROM THE NORTHEASTERN STATES AND MOVING ACROSS THE COUNTRY GRADUALLY. SO THAT TO ME IS A REALLY BIG CONCERN BECAUSE IT’S VERY DIFFICULT TO DETECT FENTANYL [INDISCERNIBLE] RATED HEROIN AND SO MANY MORE PEOPLE ARE OVERDOSING ON HEROIN BECAUSE THEY THINK THEY’RE TAKING HEROIN WHEN IT IN FACT CONTAINS FENTANYL. THIS IS THE RELATED DOSES FROM 2013 TO 2015. YOU’LL SEE THIS IS THE PERCENTAGE ACROSS THE BOTTOM. AND THERE’S A BIG INCREASE IN THE AREA AND THEY SEEM TO BE SPREAD ACROSS THE COUNTRY. SO THAT’S IT FOR THE EPIDEMIOLOGY SLIDE. I WANTED TO SPEND A FEW MINUTES ON A BRIEF HISTORY OF HOW WE GOT TO WHERE WE ARE AND THERE’S SEVERAL ILLUSTRATIONS HERE. WHAT I’M TRYING TO SAY WITH THE SLIDE IS THERE’S A COMBINATION OF ISSUES. NUMBER ONE, THERE WAS SIGNIFICANT MARKETING BY PHARMACEUTICAL INDUSTRY FOR THE PRESCRIBING OF OPIOIDS FOR CHRONIC PAIN. THERE WAS A BIG PUSH TO MAKE PAIN THE FIFTH VITAL SIGN IN THE MID 1990s AND THE JOINT COMMISSION SUPPORTED THIS PUSH TO MORE EFFECTIVELY ADDRESS PEOPLE’S PAIN. ONE OF THE THING I WANTED TO MENTION TO YOU, THE NEXT 10 OR 12 SLIDES AND I DON’T HAVE CONNECTIONS TO EITHER ONE OF THESE AUTHORS BUT THESE ARE GREAT BOOKS IF YOU’RE INTERESTED IN LEARNING MORE ABOUT THE PRESCRIPTION AND HEROIN EPIDEMIC IN THE U.S. THE FIRST IS JUST THE HISTORY OF OPIUM AND LOOKS AT IT BACK TO 3400B.C. THE OTHER IS DREAM LAND THAT LOOKS SPECIFICALLY AT HOW THE U.S. HAS GOTTEN INTO THE MESS THAT ITS IN, IN TERMS OF PRESCRIPTION OVERDOSE DEATHS AND HEROIN RELATED OVERDOSE DEATHS. IT TAKES A MORE RECENT LOOK AT THE PRESCRIPTION TO OPIOID AND HEROIN PROBLEMS. SO WHAT HAS HAPPENED AND THIS IS A LITTLE OVER 20 YEARS IS SIGNIFICANT INCREASE IN OPIOID USE OBVIOUSLY. INITIALLY DRIVEN BY PRESCRIPTION OPIOIDS PRIOR TO THE MID 1980s, PRESCRIPTION OPIOIDS WERE PRIMARILY RESERVED FOR SURGERY AND INDIVIDUALS RECOVERING FROM A SEVERE INJURY OR THOSE NEARING THE END OF THEIR LIFE. THERE WAS A LETTER TO THE EDITOR IN THE NEW ENGLAND JOURNAL OF MEDICINE AND I’LL ACTUALLY SHOW YOU THE LETTER TO THE EDITOR ON THE NEXT SLIDE BUT ESSENTIALLY THEY CONCLUDED AND PRESCRIPTION TO OPIOIDS WAS RARE. AND THE MAN WHOSE NICKNAME IS NOW KING OF PAIN SEIZED ON THE ISSUE AND ISSUED A MANUSCRIPT THAT LOOKED AT A SMALL NUMBER OF PATIENTS ON OPIOIDS FOLLOWED OVER SEVEN YEARS, 24 OF THOSE PATIENTS REPORTED ADEQUATE PAIN RELIEF. ONLY TWO OF THOSE PATIENTS, THOSE OF WHOM HAD A HISTORY OF SUBSTANCE ABUSE HAD A PROBLEM WITH THE LONG-TERM MAINTENANCE. AND THE AMERICAN PAIN SOCIETY IN THE 1990s START TO PUSH FOR PHYSICIANS AND HOSPITAL TO PUSH PAIN AS THE FIFTH VITAL SIGN. AS I MENTIONED EARLIER, THERE WERE HEAVY MARKETING IN THE PHARMACEUTICAL INDUSTRY AND IMPROVING PATIENT SATISFACTION AND ONE WAY TO IMPROVE PATIENT SATISFACTION IS TO ADDRESS PAIN AND SO THERE WAS A SHIFT IN CLINICIAN PRESCRIBING OPIATES IN THE MID TO LATE 1990s. I THINK THE NEXT SLIDE ILLUSTRATES THAT. NO, THE NEXT SLIDE IS THE LETTER TO THE EDITOR. THIS IS IT. THIS IS THE FIVE SENTENCE LETTER TO THE EDITOR FROM 1990 AND IF YOU NOTICE THE BIG ARROW THERE, THE LAST SENTENCE IS WE CONCLUDE THAT WIDESPREAD USE OF NARCOTIC DRUGS TO THE DEVELOPMENT OF ADDICTION IS RARE FOR PATIENTS WITH NO HISTORY OF ADDICTION. THAT SENTENCE HAS NOW BEEN CITED OVER 600 TIMES WITH A PARTICULAR SPIKE FOLLOWING THE RELEASE OF OXYCONTIN. 72% OF THOSE CITED ADDICTION WAS RARE AND 80% OF THOSE BY PATIENTS FAILED TO NOTE THE STUDY WAS ON IN-PATIENTS ONLY IN HOSPITAL SETTINGS AND THIS HAS BEEN CITED AS A LAND MARK STUDY DESPITE THE FACT IT WAS A FIVE-SENTENCE LETTER TO THE EDITOR. THIS IS A TABLE SHOWING THE CITATION FOR THE ARTICLE AND WHAT YOU CAN SEE IS IT WAS RELEASED IN 1980. IT WAS RELATIVELY UNNOTICED FOR DECADE OUT THERE AND THEN IT START TO GET MORE ATTENTION BEGINNING IN 1990 AND REALLY SPIKED FOLLOWING THE RELEASE OF OXYCONTIN IN THE MID ’90s. SO ESSENTIALLY THIS IS FROM AN ARTICLE PUBLISHED IN 2017 THAT WENT BACK AND LOOKED AT TRULY AT WHAT WAS LIMITED EVIDENCE PRESCRIPTION OPIOIDS CAN BE USED SAFELY FOR CHRONIC PAIN AND THE CONCLUSION OF THAT ARTICLE WAS THAT WE FOUND THAT A FIVE-SENTENCE LETTER PUBLISHED IN THE JOURNAL IN 1980 WAS UNCRITICALLY CITED THAT ADDICTION WAS RARE WITH LONG-TERM OPIOID THERAPY. SO THIS IS REALLY THE BIRTH PLACE OF THE PRESCRIPTION OPIOID EPIDEMIC AS WE KNOW IT IN THE U.S. THIS LED TO FAULTY REASONING AT THE HIGHEST LEVEL. FEDERATION OF THE STATE MEDICAL BORD REGULATION WAS THERE WOULD NOT BE ACTIONS TO DOCTORS AND THEY CALLED MEDICAL BOARDS TO MAKE TREATMENT OF PAIN PUNISHABLE. THAT PARTICULAR POLICY WAS DRAFT A SENIOR PHARMA PHYSICIAN REPRESENTATIVE. IN FACT, THE FEDERATION OF STATE MEDICAL BOARDS RECEIVED ABOUT $2 MILLION SINCE IT WAS PRODUCED IN 1997. THE JOINT COMMISSION WAS THE SAME TYPE OF ISSUE. THEY INTRODUCED AND ENFORCE THE PAIN SCALE IN THE MID TO LATE ’90s AND PUBLISHED A GUIDELINE INDICATING PRESCRIPTION IS NOT A SIGNIFICANT ISSUE WHEN PATIENT GIVEN OPIOIDS FOR PAIN CONTROL. THE RESULT WAS A TREMENDOUS SPIKE IN THE NUMBER OF OPIOID PRESCRIPTIONS DISPENSED BY U.S. PHARMACIES. THIS SLIDE’S A LITTLE BLURRY BUT YOU ESSENTIALLY SHOULD BE ABLE TO SEE IN THE EARLY ’90s TO MID ’90s THERE WAS 75,000 TO 80,000 PRESCRIPTIONS DISPENSED BY U.S. PHARMACIES AND THAT NUMBER JUST INCREASED AND INCREASED AND INCREASED UNTIL IN 2011 IT PEAKED AT 76 MILLION. — PEAKED AT 219 MILLION PRESCRIPTION FOR OPIOIDS IN 2011 AND HAS SINCE START TO TAPER OFF A BIT. IT HAS TRIPLED IN A SPAN OF ABOUT 15 YEARS. SO I MENTIONED THE KING OF PAIN AND HE HAS NOW COME BACK AND SAID I GAVE ENUMERABLE LECTURES IN THE ’80s AND ’90s THAT WERE NOT TRUE AND [INDISCERNIBLE] HAVE PLED GUILTY TO CHARGES FOR MISREPRESENTING ADDICTION TO OPIOIDS AND A QUOTE WAS WE DIDN’T KNOW THEN WHAT WE KNOW NOW. WHICH IS INTERESTING AND AGAIN WE’LL GO BACK INTO A DEEPER HISTORY. ONE OF THE THINGS YOU ALL HAVE PROBABLY HEARD AND THE SAYING THOSE WHO CAN’T REMEMBER THE PAST ARE CONDEMNED TO REPEAT IT. THAT WAS CREDITED TO [INDISCERNIBLE] WHO WAS A PHILOSOPHER. THE IDEA OF WHAT THE KING OF PAIN MAY HAVE SAID, WE DID KNOW THEN WHAT WE KNOW NOW BECAUSE OPIATES HAVE A LONG HISTORY OF MISUSE AND ADDICTION. OPIUM DATES BACK AS I MENTIONED EARLIER TO 3400 B.C. AND IT WAS REFERRED TO AS THE JOY PLANT. THERE WAS WIDESPREAD USE IN EUROPE, MIDDLE EAST AND AFRICA AND CONSIDERED A CURE FOR EVERYTHING FOR PHYSICIANS AT THAT TIME. GREEKS AND ARABS ALSO USED IT QUITE LIBERALLY. THE GREEKS RECOGNIZED THE CHARACTERISTICS OF OPIUM BUT ALSO RECOGNIZED THE CAPACITY FOR IT TO BECOME HABIT FORMING AND ADDICTION. AND WHO WROTE THE CABINET OF MEDICINE IN 1,000 A.D. DECIDE OF AN OVERDOSE TO OPIUM AND WHERE ISLAM CONQUERED OPIUM WAS DISTRIBUTED IN THOSE AREAS. TO THE RENAISSANCE, THEY FOUND LAUDNUM REFERRED TO AS SUPERIOR TO ALL OTHER HEROIC MEDICINES. IT WAS HEAVILY USED BY PHYSICIANS DURING THAT TIME AND THE RESULT WAS ADDICTION PARTICULARLY AMONG THE –. IT CAUSED EGYPTIAN TO LOSE THEIR ENERGY AND FUNCTION AND AGAIN WE SEE — WE HAVE KNOWN FOR SEVERAL HUNDRED YEARS OPIUM HAS ADDICTIVE PROPERTIES. ORIGINALLY THERE WAS PRAISE FOR LAUDNUM. HERE I CANNOT BREAK OUT IN PRAISE TO HAVE GRANT TO THE HUMAN RACE AS A COMFORT IN THEIR AFFLICTION NO MEDICINE OF THE VALUE OF OPIUM EITHER IN REGARD TO THE NUMBER OF DISEASE IT CAN CONTROL, MEDICINE WOULD BE HURTFUL WITHOUT IT. FORTUNATELY THEY ALSO RECOGNIZED THAT THERE COULD BE SERIOUS EFFECT AND IT COULD BE USED TO TREAT A NUMBER OF AILMENTS IN THE FORM OF LAUDNUM INCLUDING COUGH, DIARRHEA. AND THERE WERE QUOTES INDICATING THE PHRASE AS WELL AND WHAT CAN THEN CURE PAIN AND ALL ITS EFFECTS BETTER THAN PLEASURE. THEY REFER TO IT AS THE HAND OF GOD. THE SACRED ANCHOR OF LIFE. HERE WAS THE SECRET OF HAPPINESS AND OTHER QUOTES INDICATE THAT THEY REALIZE THERE ARE ISSUES RELATE TO OPIUM ONCE USED. IT MUST BE USED DAILY CONTINUED UNTIL DEATH A DULL AND HEAVY DISPOSITION. A COMBINATION OF JOY AND PERIL. THOSE BECAME MORE EVIDENT IN THE LATE 1800s AND 1860. ONE-THIRD OF ALL POISONINGS WERE DUE TO OPIUM. 1806, OPIUM WAS MANUFACTURED INTO MORPHINE. THE HYPODERMIC SYRINGE ESCALATED THE RECREATIONAL USE OF MORPHINE AND DISEASE EMERGED. IT REFERRED TO AS MORPHINISM OR THE SOLDIERS’ DISEASE. IT WAS ADDICTION WAS THE TERM GIVEN AT THE TIME. HEROIN WAS FIRST DISCOVERED IN 1874 BY C.R. ADDLER BROOIT LOOKING FOR THE HOLY GRAIL OF PAIN RELIEF AND MARKETED BY BAYER AT THE TIME AS A NON-ADDICTIVE COUGH SUPPRESS AND THE AND IRONICALLY AS A CURE FOR MORPHINE ADDICTION. AGAIN, A NEW PRODUCT BUT THE SAME ISSUE THAT HAS ALWAYS EXISTED THAT IS HEAVILY ADDICTED AND WHEN YOU GET INTO THE CONCENTRATED FORMS SUCH AS MORPHINE AND HEROIN, IT’S EVEN MORE ADDICTIVE. SO IT BECAME A GLOBAL SCOURGE IN THE 19th AND 20th CENTURIES. THERE WAS AN EAST INDIA TRADING COMPANY WHO EVENTUALLY TRADED OPIUM WITH CHINA IN EXCHANGE FOR TEA AND SILK AND OTHER GOODS THEY COULD RESELL IN EUROPE HEAVILY USED THROUGHOUT VIETNAM AND COLD WAR AND AN UNDERGROUND ECONOMY EMERGED KNOWN AS NARCO ECONOMICS AND HAS BEEN HEAVILY LINKED TO HUMAN TRAFFICKING IN THE SENSE THAT THE MEN BECOME ADDICT TO HEROIN AND WILL USE THEIR PARTNERS, SPOUSES, GIRLFRIENDS IN THE SEX TRADE TO PURCHASE MORE HEROIN FOR THEM AND THEIR PARTNER. SO WHAT WE DIDN’T KNOW THEN WHAT WE KNOW NOW IS PATENTLY FALSE HISTORY REPEATED ITSELF AGAIN IN THE LATE 20th CENTURY. WHAT YOU SEE TO THE RIGHT THERE IS A STATEMENT FROM THE AMERICAN ACADEMY OF PAIN SOCIETY ON OPIOIDS FOR TREATMENT ON CHRONIC PAIN AND I’VE HIGHLIGHTED JUST A PARAGRAPH HERE, PAIN IS OFTEN MANAGED INADEQUATELY DESPITE THE READY AVAILABILITY OF SAFE AND EFFECTIVE TREATMENT OF SAFE OPIOIDS. THAT’S A BACKGROUND HOW WE GOT IN THE MESS WE’VE GOTTEN INTO. MORE RECENTLY, PEOPLE ARE PAYING MORE ATTENTION TO THE REAL EVIDENCE OF LONG-TERM OPIOID TREATMENT OVER THE PAST THREE YEARS, THERE’S BEEN THREE SYSTEMATIC REVIEWS THAT LOOKED AT LONG-TERM OPIOID TREATMENT FOR CHRONIC PAIN. NHRQ SYSTEMATIC REVIEW REPORTED THERE WAS REALLY NO STUDY OF OPIOID VERSUS A PLACEBO EFFECT. NO STUDY OF AN OPIOID VERSUS A NON-OPIOID PRESCRIPTION EVALUATED WITH A GREATER THAN ONE-YEAR OUTCOME. MOST THE RCPs IN THE SYSTEMATIC REVIEWS HAD OUTCOMES OF LESS THAN SIX WEEKS. AND NO ONE KNEW WHAT THE LONG-TERM OUTCOME OF LONG-TERM OPIOID TREATMENT WAS GOING TO BE. IN FACT, THIS SYSTEMATIC REVIEW REPORTED THAT THERE IS MORE EVIDENCE AVAILABLE ON THE HARMS OF LONG-TERM OPIOID TREATMENT INCLUDING AN INCREASED RISK OF OVERDOSE AND GRADUALLY INCREASING TOLERANCE WITH HIGHER DOSES INCREASING THE RISK OF OVERDOSE AND ABUSE AND DEPENDENCE. FRACTURES, MEANING FALLS RELATED TO TAKING PRESCRIPTION OPIOIDS. IN THIS SLIDE THIS SHOWED THIS WAS FROM ANOTHER STUDY IN THE LAST YEAR SHOWS THE PROBABILITY OF CONTINUING TO TAKE PRESCRIPTION OPIATES AFTER JUST A SINGLE PRESCRIPTION FOR OPIOIDS. ESSENTIALLY, IT’S SHOWING IF YOU GET — HOW MANY DAYS SUPPLY AND BASED ON THE NUMBER OF DAYS SUPPLY OF THE FIRST PRESCRIPTION, WHAT ARE THE ODDS THAT YOU’LL STILL BE TAKING PRESCRIPTION OPIATES ONE YEAR LATER AND THREE YEARS LATER. SO IF YOU LOOK, FOR EXAMPLE, IF AN INDIVIDUAL GETS AN INITIAL PRESCRIPTION OF A 30-DAY PRESCRIPTION THE ODDS THEY’LL STILL BE TAKING A PRESCRIPTION OPIATE ONE YEAR LATER IS 35% TO 40%. AND THREE YEARS LATER, 20% TO 25% WILL STILL BE TAKING PRESCRIPTION OPIATES THREE YEARS LATER BASED ON A 30-DAY INITIAL PRESCRIPTION. SO ADDRESSING THE EPIDEMIC FROM A PUBLIC HEALTH APPROACH. IT’S RECOGNIZED IN THE U.S. AND WE’RE MAKING SOME EFFORTS TO ADDRESS THE PRESCRIPTION OPIATE AND HEROIN CRISIS. THESE ARE HEADLINES FROM THE LAST YEAR. THE CDS ANNOUNCED IT WOULD LIMIT OPIATE DRUG PRESCRIPTIONS AS PART OF A NATIONAL EPIDEMIC. SO IF YOU COME INTO CVS WITH A PRESCRIPTION FOR 30 DAYS I THINK THEY’RE ONLY FILLING A SEVEN-DAY PRESCRIPTION. PRESIDENT TRUMP IN LATE 2017 DECLARED THE OPIOID CRISIS A PUBLIC HEALTH EMERGENCY. THERE WAS A COMMISSION ON THE OPIOID EPIDEMIC. I’LL SHOW YOU THE HEADLINE TO THAT REPORT AND A SLIDE IN A FEW MINUTES. LOTS ARE CUTTING BACK ON OPIOIDS AND WE’RE STARTING TO SEE HEADLINES IN THE NEWS TO SUGGEST WE’RE TAKING STEPS IN THE RIGHT DIRECTION. IN TERMS OF APPROACHING IT FROM A PUBLIC HEALTH PERSPECTIVE, ONE AREA THAT WE WOULD NEED TO FOCUS ON IS PRIMARY PREVENTION. THESE ARE A FEW OF THE PREVENTION RESOURCES AVAILABLE PRIMARILY FOR SCHOOLS AND FOR YOUNGER PEOPLE. THERE IS A PROGRAM CALLED NOT PRESCRIBE THAT CAN BE IMPLEMENTED AND AS A CLASSROOM THERE’S ONE CALLED OPERATION PREVENTION THAT AGAIN IS FOCUSSED ON STUDENTS, TEACHERS AND PARENTS AND ANOTHER CALLED PREVENTION PLUS WELLNESS THAT’S SIMILAR IN THE SENSE IT’S FOCUSSED ON YOUNGER YOUTH AND ADOLESCENTS. THE OTHER PRIMARY POSITION APPROACH IS FUND THE NATIONAL INSTITUTE ON DRUG ABUSE THE PROVIDERS CLINICAL SUPPORT SYSTEM FOR OPIOID THERAPIES AND ITS ROLE IS TO TRAIN AND MENTOR PHYSICIANS ON THE SAFE AND EFFECTIVE USE OF OPIOID MEDICATION. SAMSA ALSO FUNDS A NUMBER OF TRAINING GRANTS TO TEACH PEOPLE TO DO SCREENING AND BRIEF INTERVENTION AND REFERRALS TO TREATMENT. AND THE HILTON FOUNDATION ALSO HAS A NUMBER OF GRANTS TO BETTER ADDRESS SUBSTANCE USE AND ABUSE IN ADOLESCENTS. PRESCRIPTION DRUG MONITORING PROGRAMS ARE NOW IN EXISTENCE IN EVERY STATE AND YOU’LL SEE THE HEADLINE AT THE BOTTOM. LAST YEAR MISSOURI BECAME THE LAST YEAR TO CREATE A PRESCRIPTION DRUG MONITORING PROGRAM AND ESSENTIALLY THE PURPOSE OF THOSE IS TO PREVENT DOCTOR SHOPPING. SO PHYSICIAN SUPPOSED TO CHECK THE PDMPs PRIOR TO PRESCRIBING TO MAKE SURE THEY DON’T HAVE ANOTHER PRESCRIPTION BY ANOTHER PHYSICIAN. IF YOU’RE ON A BORDER CITY, THE WAY I AM, IF IT’S RIGHT ON THE BORDER OF GEORGIA AND SOUTH CAROLINA, THEORETICALLY A PATIENT CAN GET A PRESCRIPTION IN GEORGIA AND DRIVE ACROSS THE STATE LINE TO A PHYSICIAN OVER THERE AND THE PDMP BETWEEN THE TWO STATES WOULD NOT COMMUNICATE WITH EACH OTHER. YOU CAN’T SEE THAT VERY WELL. THIS SHOWS IT’S BEEN EFFECTIVE AND INFORMATION ON WHERE THE INDIVIDUAL’S ACHIEVED THEIR MOST RECENT OPIOID AND 1.4% REPORT THEY HAVE A PRESCRIPTION FROM MORE THAN ONE PHYSICIAN. THE MAJORITY OF THE ACCESS TO OPIOIDS ACTUALLY CONTINUES TO COME THROUGH FAMILY MEMBERS OR FRIENDS WHICH IS THIS LIGHT BROWN AREA. SO MEDICATION ASSISTED TREATMENT AND OPIOID USE DISORDERS. THERE’S THREE FDA PRESCRIPTIONS, METHADONE AND NALOXONE USED TO REVERSE OVERDOSES. IN DECEMBER OF 2017, SO IN THE LAST SIX OR SEVEN MONTHS, THE FDA APPROVED AN INJECTABLE. SO METHADONE IS A HEROIN AGONIST AND IT DOESN’T GIVE THE SAME HIGH HEROIN OR OXYCODONE WOULD. IT’S BEEN SHOWN TO REDUCE DRUG USE AND AN EFFECTIVE DOSE IS 120 MILLIGRAMS A DAY. A METHADONE PROGRAM. YOU CANNOT PRESCRIBE METHADONE MAINTENANCE THROUGH PRIMARY CARE. AND THERE’S REGULAR EUROPE DRUG SCREEN AND MONITORING FOR DRUG USE AND SOCIAL PROBLEMS. IN TERMS OF OUTCOMES, I MENTIONED NUMEROUS RANDOMIZED CONTROL TRIALS AND IT REDUCES MORTALITY AND THE RISK OF HIV INFECTION AND SO ON. I KNOW IT’S QUITE EFFECTIVE. THE ISSUE THOUGH IS THAT THERE’S LIMITED AVAILABILITY. ONLY AVAILABLE IN LICENSED CLINIC AND THEY TEND TO BE IN URBAN AREAS AND THE PRESCRIPTION EPIDEMIC IS IN PLACE WHERE’S METHADONE CLINICS WOULD NOT BE LOCATED. AND IF THERE IS A STIGMA THAT CONTINUES TO BE ASSOCIATED WITH GOING TO METHADONE PROGRAMS AND THEY’RE HEAVILY REGULATED REQUIRING DAILY ATTENDANCE SO IT CAN FEEL QUITE OPPRESSIVE AND LIKE YOU’RE IN SHACKLES WHERE YOU HAVE TO REPORT EACH DAY TO GET YOUR DOSE. APOMORPHINE CAN BE TAKEN AND THERE’S THE IMPLANT AS WELL AS THE ONCE MONTHLY INJECTABLE. THERE ARE GUIDELINE TO GOVERNING APOMORPHINE AND YOU HAVE TO REGISTER WITH AND THEY CAN MAKE VISIT AND INSPECT YOUR OFFICE AND MAKE SURE YOU’RE USING IT APPROPRIATELY. THIS WAS EXPANDED THROUGH THE COMPREHENSIVE AND RECOVERY ACT OF 2016. IT HAD THE GOAL OF EXPANDING PREVENTION EDUCATION AND DISTRIBUTING NALOXONE AND TREATMENT AND THE RESULT WAS PHYSICIANS CAN NOW HAVE UP TO 275 PATIENTS ON IT AND ALSO AUTHORIZED NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS TO PRESCRIBE IT BUT INTERESTINGLY THEY HAVE TO COMPLETE FOUR HOURS NOT EIGHT HOURS REQUIRED OF PHYSICIANS. SO THIS IS THE NUMBER OF CERTIFIED PHYSICIANS IN THE U.S. THERE’S 37,000 PHYSICIANS WHO HAVE BEEN CERTIFIED AND ARE ALLOWED TO PRESCRIBE IT. MOST ARE STILL AT THE 30-PATIENT LIMIT. THEY HAVEN’T ADVANCED BEYOND THE 30-PATIENT LIMIT. ONLY A SMALL PORTION HAVE BEEN CERTIFIED FOR THE 275 PATIENT LIMIT. IT’S BEEN DIFFICULT TO GET PHYSICIAN TO DEAL WITH THE STIGMA ASSOCIATED WITH DRUG AUSE AND DIFFICULT TO GET PHYSICIANS IN PRIMARY CARE TO UNDER GO THE TRAINING AND START TAKING ON BUPRENORPHINE PATIENTS AND A RECENT STUDY LOOKED AT REASONS THAT PHYSICIANS DON’T PRESCRIBE AND THEY CITE A LACK OF TRAINING AND INSTITUTIONAL SUPPORT AND MENTAL HEALTH AND PSYCHO SOCIAL SUPPORT WITHIN THEIR AREAS. LOW REIMBURSEMENT, LACK OF STAFF TRAINING, LACK OF TIME, STIGMA. THERE’S LOTS OF BARRIERS TO BEING ABLE TO ADEQUATELY PROVIDE MEDICATION ASSISTED TREATMENT IN THE PRIMARY CARE SETTING. NOW VIVITROL IS A ONCE-MONTHLY INJECTION APPROVED BY THE FDA IN 2010. KEY POINTS ABOUT IT CAN BE AT MINISTERED AND IT’S AN INTRAMUSCULAR INJECTION. SOME DOWN SIDES TO IT ARE THE POTENTIAL FOR ADVERSE REACTION AT THE INTERSECTION SITE AND THEN THE COST IS PROHIBITIVE IN A LOT OF WAYS. IT COSTS ABOUT $1300 PER MONTH FOR VIVITROL. AS I MENTIONED, NALOXONE IS AN OPIOID ANTAGONIST THAT DISPLACE THE OPIOID AGONIST IN CASE OF AN OVERDOSE. AND THERE’S RESCUE PERSONNEL. THE C.D.C. GUIDELINES ENCOURAGE TO CONSIDER NALOXONE PRESCRIPTIONS WITH HIGHER OPIOID DOSES OR HISTORY OF OVERDOSE OR HISTORY OF SUBSTANCE USE DISORDERS. A LOT OF STATES NOW INCLUDING GEORGIA HAVE THIS WILL ALLOW PHARMACIES TO DISTRIBUTE NALOXONE WITHOUT A PRESCRIPTION. THE DIRECTOR OF THE STATE DEPARTMENT OF PUBLIC HEALTH BECOMES THE PHYSICIAN OF RECORD SO FAMILY MEMBERS ARE ACTIVE USERS THAT ARE CONCERNED ABOUT AN OVERDOSE CAN GO IN AND GET A NALOXONE IN THE FORM OF NASAL SPRAY FROM PHARMACIES WOULD AN ADDITIONAL PRESCRIPTION. AND THE PRESCRIPTION TREATMENT AND THERE’S ACCESSIBILITY. METHADONE TREATMENTS TEND TO BE CONCENTRATED IN URBAN AREAS AND MUCH OF THE EPIDEMIC HAS BEEN IN RURAL AREAS AND THERE’S STIGMA AND TIME INVOLVED IN GETTING YOUR DAILY DOSE. INSURANCE COVERAGE HAS BEEN NOT STRONG FOR THE MEDICATION ASSISTED TREATMENT. SOME STATES LIMIT THE AMOUNT OF TIME THE MEDICATION CAN BE USED AND IN SOME STATES MEDICAID CAN’T COVER THE THREE I MENTIONED. SOW ONE EXAMPLE THAT HAS NOT BEEN TRIED IN THE U.S. THAT IS PROMISING IN CANADA IN VANCOUVER IS NORTH AMERICA’S FIRST LEGALIZED INJECTION SITE. IT’S SOMETHING THE U.S. MAY WANT TO CONSIDER TO CUT DOWN ON THE NUMBER OF OVERDOSE DEATHS. THE DRUGS HAVE TO BE PERSONALLY ACQUIRED BUT THE INJECTION SITE PROVIDES CLEAN SYRINGES, NEEDLES, SAFE DISPOSAL AND SAFE SEX EDUCATION AND NURSES AND A DIRECT LINK TO SUBSTANCE USE DISORDER TREATMENT IF THE INDIVIDUAL IS INTERESTED IN SEEKING TREATMENT. THE PRESIDENT’S COMMITMENT ON BATTLING THE OPIOID CRISIS JUST RELEASED IN NOVEMBER OF 2017 AND HERE ARE SOME VERY RECENT REQUEST FOR APPLICATIONS FROM SAMSA AND HRSA WHICH ARE STATE OPIOID RESPONSE GRANTS GIVEN TO STATES TO INCREASE THE USE OF THE AVAILABILITY OF TREATMENT AND THE USE OF NALOXONE AND FOCUSSING ON COMMUNITIES AND THE FIRST ROUND HAVE PLANNING GRANTS. IDENTIFYING THE GAPS IN THE COMMUNITIES AND THEN CREATING A STRATEGIC PLAN TO ADDRESS THE GAPS. MORE IS NEEDED. WHAT WE NEED IS A COMPREHENSIVE STRATEGY FOR TREATMENT AND CONSUMER-DIRECTED MEDIA CAMPAIGNS AND PUBLIC EDUCATION ABOUT NALOXONE. INCREASE PRESCRIBER USE OF THE P MP BECAUSE IN MOST CASES YOU HAVE TO GET OUT OF THE ELECTRONIC HEALTH RECORD TO ACCESS THE PDMP. PHYSICIANS HAVE BEEN HESITANT TO USE IT AND DON’T USE IT AS FREQUENTLY AS THEY SHOULD. INSURANCE TO INCREASE TREATMENT. IN TERMS OF TREATMENT, WE NEED AN INCREASED USE OF MEDICATION-ASSISTED TREATMENT EXPANDING TREATMENT ACCESS AND CAPACITY, INCENTIVIZING PROVIDERS TO ENHANCE THE QUALITY OF SCREENERS AND IDENTIFY PEOPLE AT RISK BEFORE THEY PROGRESS TO DEPENDENCE OR BEFORE THEY OVERDOSE. AND THEN OVERDOSE PREVENTION, EXPANDING NALOXONE AVAILABILITY AND GEORGIA HAS A STANDING ORDER FOR GETTING NALOXONE INTO THE HANDS TO THOSE WHO NEED IT. SOME STATES HAVE A STANDING ORDER AND ENGAGE IN SITES AND A RESPONSE TO OUTBREAKS, ETCETERA. THE OTHER PIECE OF THE DASHBOARD IS WHERE WE HAVE ALL THE INFORMATION COMING IN SO WE COULD RESPONSE AS NEEDED. PARTICULARLY TO HIGH-RISK AREAS. WHILE THAT’S THE IDEA, IT’S NOT REALITY, THIS IS THE WORLD THAT WE LIVE IN. THIS IS A SIGN OUTSIDE A COURTROOM AND WE WON’T FOCUS ON THE SPELLING THERE BUT THEY ESSENTIALLY MISSPELLED WORDS AND THERE’S MEDICATION ATTACHED TO TREATMENT AND VIEWED AS A REPLACEMENT INSTEAD OF [INDISCERNIBLE] . THIS IS A QUOTE FROM OUR FORMER SECRETARY OF HEALTH AND HUMAN SERVICE WHO’S TOUTED FAITH-BASED PROGRAMS AND WAS NOT SUPPORTIVE OF MEDICATION TREATMENT AND HE SAID THEY NEED TO BE PRODUCTIVE MEMBERS OF SOCIETY AND REALIZE THEIR DREAMS. AND THEN JEFF SESSIONS IN MAY OF LAST YEAR HAD CALLED FOR HARSHER SENTENCING FOR SIMPLE POSSESSION OF DRUGS ESSENTIALLY MOVING IN THE WRONG DIRECTION. AND SO THAT’S WHERE WE ARE. THAT’S MY PRESENTATION AND I’LL BE HAPPY TO ANSWER ANY QUESTIONS YOU MAY HAVE OR HEAR ANY FEEDBACK YOU MAY HAVE BUT THANKS FOR LISTENING. BACK TO AMY.>>THAT WAS AN AWESOME PRESENTATION –>>YOU SAID MEDICARE DOESN’T COVER THE DRUG FOR THE PERSON DOES IT PREVENT THE DISTRIBUTION OF OPIOIDS INITIALLY? I’M NOT SURE I UNDERSTAND THE QUESTION.>>ANGELA, DO YOU WANT TO CLARIFY YOUR QUESTION? I THINK WHAT SHE’S ASKING. ARE THERE MEASURES. ANGELA SAYS DOES MEDICARE PREVENT DOCTORS FROM SHARING –>>NO, NOT THAT I’M AWARE OF. SO MEDICARE WOULD COVER THE PRESCRIPTION OPIOID FOR HYDROCODONE, ETCETERA. YEAH, THAT IS NOT AN ISSUE. AND IT’S MEDICAID MORE THAN MEDICARE. IT VARIES BY STATE. SO MEDICAID IN SOME STATES WILL COVER THE THREE APPROVED MEDICATION-ASSISTED THERAPIES BUT IT DOES NOT IN ALL STATES SO FOR EXAMPLE, IT MAY COVER METHADONE FOR A LIMITED LENGTH OF TIME AND THEY MAY COVER BUPRENORPHINE. SO YEAH, MEDICARE COVERS OXYCODONE AND NOT NECESSARILY PLACE LIMITS ON PHYSICIANS IN TERMS OF HOW THEY CAN PRESCRIBE THOSE.>>GREAT. SO ONE MORE QUESTION IN THE BOX THERE.>>CAN YOU COMMENT ON THE QUALITY OF DATA ACROSS THE COUNTRY AND HOW THAT MAY EFFECT THE RESOURCING FOR AREAS POSSIBLY IN GREATER NEEDS THAN DEMONSTRATED BY THE DATA AT PRESENT. THAT’S A GOOD QUESTION AND THE QUALITY OF THE DATA VARIES BY STATE TO STATE AND A LOT OF STATES WERE WAY BEHIND IN TERMS OF GETTING RAPID, UP TO DATE DATA. WHAT YOU MAY HAVE NOTICED IN MY PRESENTATION IS EVEN AT A NATIONAL LEVEL AND THE MOST RECENTLY AVAILABLE DATA IS FROM 2016 AND WE’RE NOW SIX MONTHS INTO 2018. SO GETTING RAPID — REAL-TIME, UP TO DATE, DATA SAY FOR EXAMPLE OUTBREAKS AND OVERDOSES IN A CERTAIN COUNTY OR NEIGHBORHOOD WOULD BE NEXT TO IMPOSSIBLE. THERE ARE STATES THAT ARE TRYING TO MAKE HEADWAY IN THAT AND GEORGIA IS ACTUALLY ONE OF THEM. I DON’T KNOW EXACTLY WHAT OTHER STATES ARE DOING BUT I’M PART OF A STRATEGIC PLANNING COMMITTEE THAT’S BEING RUN BY THE STATE DEPARTMENT OF PUBLIC HEALTH IN GEORGIA SO THEY’RE BRINGING TOGETHER STAKEHOLDERS FROM ALL OVER THE STATE AND AT ALL LEVELS TO TRY AND DO A BETTER JOB OF GETTING REAL-TIME DATA AND GETTING HELP WHERE HELP IS MOST NEEDED. OKAY.>>WE HAVE ONE MORE QUESTION.>>SURE, IT WOULD SEEM MORE PROGRAMS TO COMBAT OPIOIDS PROVEN TO WORK IN OTHER COUNTRIES U.K. AND CANADA ARE NOT READILY ADOPTED IN THE U.S. IS THERE ANY PARTICULAR REASON FOR THAT? I CAN TELL YOU THE REASON THAT THE SAFE INJECTION SITE IN VANCOUVER HAS NOT BEEN ADOPTED IN THE U.S. AND THAT IS BECAUSE THE POLITICAL CLIMATE OF THE U.S. WOULD NOT ALLOW FOR THAT. IT WOULD BE VERY DIFFICULT TO IMPLEMENT THAT TYPE OF PROGRAM IN THIS COUNTRY BECAUSE PEOPLE JUST AREN’T OPEN-MINDED TO THAT TYPE OF APPROACH. OUR COUNTRY CONTINUES TO BE VERY FOCUSSED ON CRIMINAL PUNISHMENT FOR DRUG USERS VERSUS A DIFFERENT APPROACH AND AN INJECTION SITE LIKE THAT WOULD NOT BE WELCOME IN THE U.S. SO THERE’S STILL A LOT OF WORK TO DO TO ADDRESS THE STIGMA THAT WE SEE HERE. THAT’S ALSO WHY WE DON’T SEE WIDESPREAD USE OF NEEDLE EXCHANGE PROGRAMS.>>OKAY. THANK YOU EVERYONE SO MUCH FOR THE GREAT QUESTIONS AND THANK YOU AARON FOR THE PRESENTATION. AS A REMINDER THE PRESENTATION TODAY WAS RECORDED AND WILL BE POSTED ON THE NLM YOUTUBE PAGE AS SOON AS WE CAN. I ALSO ENCOURAGE YOU TO SUBSCRIBE TO THE YOUTUBE CHANNEL TO BE NOTIFIED AS SOON AS NEW RECORDINGS ARE AVAILABLE AND I’LL SHARE THE LINK IN THE CHAT BOX. AARON HAS AGREED TO LET US SHARE HIS PRESENTATION SLIDES SO ONCE THE RECORDING IS AVAILABLE ON YOUTUBE I’LL E-MAIL EVERYONE A LINK TO THE RECORDING AND SEND A PDF OF THE SLIDE IN THE NEXT COUPLE WEEKS TO THOSE WHO REGISTERED FOR THE WEBINAR. THE NEXT WEBINAR IS TAKE PLACE THURSDAY AUGUST 23 AT 2:00 P.M. EASTERN. THE WEBINAR IS AN JOURNAL CLUB ON MEDICINE AND DETAILS ARE AVAILABLE AT NNLM.gov. TO EVALUATE TODAY’S WEBINAR AND RECEIVE YOUR NLA CE CREDIT PLEASE VISIT THE FOLLOWING LINK. I’LL POST THAT IN THE CHAT BOX AS WELL. ONCE IT’S BEEN COMPLETED YOU’LL RECEIVE INSTRUCTIONS HOW TO RECEIVE CREDITS THROUGH THE WEBSITE AND THANKS AGAIN EVERYONE FOR ATTENDING THE WEBINAR AND THANK YOU, SO MUCH, AARON FOR TAKING TIME TO PRESENT. IT WAS WONDERFUL. YOU ALL HAVE A GREAT AFTERNOON. THANKS AGAIN.>>THANKS, EVERYBODY. ENJOYED IT.>>THANK YOU, SO MUCH, AARON.>>THANKS, BYE.>>BYE.

Roly Polies Came From the Sea to Conquer the Earth | Deep Look

Roly Polies Came From the Sea to Conquer the Earth | Deep Look


Pill bugs…… roly polies….. potato bugs… whatever you want to call them, somehow there’s something less creepy about these guys than other insects. More loveable, or something. Maybe it’s because they’re not insects
at all. Pill bugs are actually crustaceans. They’re more closely related to shrimp and
lobsters than crickets or beetles. Pill bugs even taste like shellfish, if you
cook them right. Some adventurous foragers call them wood shrimp. As early as 300 million years ago, some intrepid
ancestor crawled out of the ocean, sensing there might be more to eat, or less competition,
on dry land.” But unlike lobsters, pillbugs can roll up
into a perfect little ball for protection. If you look closely you can see the evidence
of where these guys came from. Like their ocean-dwelling cousins, pill bugs
still use gills to breathe. True insects — like this cricket — use a
totally different system. See those tiny holes on this cricket’s abdomen? They’re called spiracles. They lead to a series of tubes that bring
fresh air directly to the insect’s cells. But pill bugs don’t have any of that. To survive on land, they had to adapt. Their gills, called pleopods, are modified
to work in air. Folds in the pleopod gills developed into
hollow branched structures, almost like tiny lungs. In a way, the pillbug is only halfway to becoming
a true land animal. Because… they’re still gills. They need to be kept moist in order to work. Which is why you usually find pill bugs in
moist places, like under damp, rotting logs. They can’t venture too far away. Sure, pill bugs look like the most ordinary
of bugs. But they’re much more than that: evidence
that over evolutionary time, species make big, life-changing leaps. And those stories are written on their bodies. Hey, while we’re on the subject of oddball
crustaceans… check out this episode about mantis shrimp. Their eyes see colors we can’t even
comprehend. Their punch is faster than Muhammad Ali’s. And while we have you: Subscribe. OK? Thank you! And see you next time.