Ohio’s Abuse Epidemic: Treatment Can Work

1. Ohio’s Abuse Epidemic: Treatment Can Work Rehabilitation Care Group Nino DiIullo, MD and Karl Valentine, MD

2. Presentation Overview • Review statistics on drug overdose deaths in Ohio • Discussion of factors contributing to this problem • Anatomy of addiction • State response to addiction epidemic • How Rehabilitation Care Group treats this problem

3. The Epidemic of Drug Abuse • Drug abuse has become a major national problem • In 2013, nearly 44,000 people died from drug overdoses • The number of deaths has more than doubled since 1999 • Ohio has the 8th highest drug overdose rate in the U.S. • The leading cause of accidental death in Ohio is overdose • The number of deaths has increased 440% since 1999 • On average, 6 Ohioans die each day from drug overdose • The cost to the community isn’t just personal • More than $2.5 billion is lost each year due to drug overdose fatalities • Non-fatal, drug poisonings requiring hospitalization cost $31.9 million

6. Contributing Factors: Social and Environmental • 40% – 60% of vulnerability to addiction can be attributed to genetic and environmental factors • Low socioeconomic group and lack of education can increase abuse, but addiction ranges across all social classes. • Poor parental support contributes to addiction among youths • Mental illness also significantly increases risk of drug abuse

7. Contributing Factors: Drug Availability • Pain relief laws passed in 1997 expanded the usage of potent pain medicine in response to recognition of pain as 5th vital sign • 2 out of 3 patients who visit a doctor leave with at least one prescription for medication • More than $234 billion was spend on prescription drugs in 2008, almost 6 times the amount spent in 1990 • Perceived legitimacy of prescription drugs • Increasing availability of drugs on the internet

9. Contributing Factors: Upsurge in Heroin • Legislative changes in 2012 helped shut down the “pill mills” and restrict access to prescription opiates • Price of prescription drugs on the black market skyrocketed • Heroin has now become the cheap drug of choice • Number of heroin abuse cases is now on the rise

11. Contributing Factors: Youth Addiction • More than 1 in 5 Ohio high school students reported using a prescription drug without a doctor’s authorization in 2011 • 49% of these students used narcotic pain relievers • Every day 2,700 teens abuse a prescription drug for the first time. • 8 out of 10 who misuse prescription drugs get these drugs from friends or family

12. Anatomy of Addiction

13. Anatomy of Addiction • The limbic system is highly interconnected and the structures are essential not only for learning and memory but also for the emotional context and the affective right and wrong response to learned association. • Many drugs of abuse have their sites of action within the limbic system and the neurochemistry within the structures is altered during the addiction process. • Dopamine plays a central role in reward and drug addiction.

14. Anatomy of Addiction • The neuroanatomy of addiction and human subjects has documented metabolic changes noted on PET scan. • Addiction results in deeply ingrained memories capable of creating intense urges and patient exposed to triggers – emotional or sensory, after years of log abstinence.

15. Biology of the Brain 1 Non-Opioid Dependent Brain Opioid Dependent Brain PET scan images show changes in brain function caused by opioid dependence. The lack of red in the opioid-dependent brain shows a reduction in brain function in these regions.

16. Biology of the Brain2

17. Biology of the Brain3

18. Biology of the brain • Drug addiction is a disease of the brain associated with abnormal behavior. • Drugs of abuse provide longer and larger highs • 5-10 times increases in dopamine to the brain than natural rein forcers as an food or sex. • Opioid Dependence is a Chronic Brain Disease shown to cause: 1 • Pervasive changes in cognitive and drug-rewarding circuits 1 • Significant altercations in the neurochemical, molecular and cellular levels 1 • Changes to brain structure and function that persist long aver the drug has ceased 1

20. Dopamine Pathways and Addiction

22. State Response • Legislation – HB 93 • Addresses the Physician component • Licensing of pain management clinics • Sets dispensing limits • Updated OARRS rules • GCOAT – Governor’s Cabinet Opiate Action Team • Addresses the misuse, abuse and overdose from prescription opioids • Treatment • Education • Enforcement • Recover Supports • Professional Education

23. How We Fit In • Rehabilitation Care Group – RCG • Established, outpatient treatment program for opioid addiction • Confidential, understanding, no judgment environment • Licensed Physicians Educated in Substance Abuse • Our Two Step Approach 1. Address the three C’s 2. Address the psychosocial and environmental factors influencing the individual’s decisions

24. Step One • Address the 3 C’s • Control • Craving • Continued use • Recovery with the assistance of Vivitrol

25. Vivitrol • What is Vivitrol? • Extended-release dose of naltrexone • Medicine provided in a single, monthly shot by a medical professional • Used for both alcohol and opioid dependence treatment. • How does Naltrexone work? • Opioid antagonist that has the highest binding affinity to mu-opiod receptors • Creates a 1 month opioid blockade • Does not stimulate the dopamine reward pathway • Not addictive and does not lead to physical dependence or withdrawal • Very effective blocker for both alcohol and mu-receptors

26. Opioid Effect on the Brain

27. Naltrexone’s Effect on mu-receptors

28. Naltrexone vs. Buprenorphine •  Opioid Antagonist vs. Agonist • Buprenorphine has a very strong affinity to the opioid mu receptor. It completely activates the receptor to prevent other opioids from activating it. • Naltrexone blocks access to the opioid mu receptor. The receptors cannot activate because the naltrexone blocks opioid access to them. • Diversion risk • Buprenorphine is commonly taken daily so there is a risk of medicine being sold on secondary market • Extended-release naltrexone is administered in office, no chance of diversion • Control over Dosage • Buprenorphine is self-administered. Patients can vary their dosage by over or under administering medicine. • Vivitrol dosages are set and administered by doctor. Doctor would need to adjust dosage at monthly appointment.

29. Step Two • Address the psychosocial and environmental factors • The What and The Why • In House, Licensed Counselors • IOP Counseling • Individual, Family and Group • Focus: Early recovery skills, relapse prevention, family education and social support • Continued Counseling • Family and Group • Focus: Identifying triggers, preventing relapse, the family role of recovery

31. Our Program • Prescreening • All patients receive an initial phone consultation with an intake specialist • Educates them on our program • Determines if the program is a good fit for them • Induction Visit • First Visit – With Physician • Patient presents post-withdrawal or begins withdrawal protocol • First dose administered • Discharge upon stabilization • Follow Up Visits • Two weeks after induction • Monthly, thereafter

32. How we are different • Commitment • We are committed to our patients and to their recovery • We ask our patients to commit to us • Compassion • Addiction doesn’t discriminate • Understand that addiction is different for everyone • Tailor our program to fit the needs of the patient • Education • Knowledge is power. The more prepared our patient, the better their chance at success • Understanding • There will be difficult times, there will be challenges – even setbacks • No judgment – even if relapse occurs

33. For Additional Information, please contact: Nikki Williams, Clinic Manager nwilliams@treatmentcanwork.com Dr. Karl Valentine, Medical Director kvalentine@treatmentcanwork.com Dr. Nino DiIullo, Owner ninodi@aol.com Phone: (614) 901-0590

34. References: Slide 3: Data from http://www.healthy.ohio.gov/vipp/drug/dpoison.aspx Slide 4: ODH Office of Vital Statistics* Slide 5: 1) ODH Office of Vital , Statistics; 2) Ohio Department of Public Safety, Ohio Traffic Crash Facts* Slide 6: 1) SAMHSA Treatment Episode Data Set (TEDS); 2) Drug Abuse Warning Network (DAWN); 3) National Survey of Drug Use in Households (NSDUH) * Slide 8: Institute for Safe Medication Practices* Slide 9: 1) WONDER (NCHS Compressed Mortality File, 1979-1998 & 1999-2005) 2) 2006-2011 ODH Office of Vital Statistics, 3) Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999)* Slide 10: DOJ, DEA, and ARCOS reports* Slide 12: 1) WONDER (NCHS Compressed Mortality File, 1979-1998 & 1999-2005) 2) 2006-2011 ODH Office of Vital Statistics, 3) Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999)* Slide 13: 1) ODH, Ohio Youth Risk Behavior Survey; 2) SAMHSA’s National Survey on Drug Use; 3) SAMHSA’s National Survey on Drug Use* Slide 17: A.D.A.M. Health Solutions. A.D.A.M Images. Retrieved from http://adamimages.com Slide 18: Reckitt Benckiser Pharmaceuticals Inc., 2011, Evolving Treatment, Empowering Patients. Slide 19: R., Fiellin, D., Miller, S. & Saitz, R. (2009). Principles of Addiction Medicine. Slide 25: Image from http://www.rb.com/rbpharmaceuticals/developing-markets • Images taken from Ohio Department of Health slideshow presentation: Ohio’s Prescription Drug Overdose Epidemic available at: http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/PHW20pres1.ashx