Pain Relievers Are Leading to a New Drug Injection Epidemic

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Meet: Ricky Bluthenthal, PhD

Receive an overview of how the prescription opioid epidemic is the first truly national drug epidemic in US history. Understand how the ongoing prescription opioid epidemic is leading to significant increases in injection drug use and injection-related disease epidemics (e.g., HCV, endocarditis, skin and soft tissue infections, among others in the US).

Learn more about generational changes in drug preference and their impacts on injection drug use behaviors and drug-specific characteristics that facilitate transitions to injection drug use. Become aware of the consequences of the prescription opioid epidemic and what is needed in terms of aggressive prevention, treatment, and care interventions.

The University of Southern California’s Master of Public Health

Ricky Bluthenthal, Ph.D. Professor of Preventive Medicine Core Courses

Dr. Bluthenthal has written more than 95 articles in peer-reviewed scientific journals such as the American Journal of Public Health, Social Science & Medicine, The Lancet, Addiction, and Alcoholism: Clinical and Experimental Research, among others. His current studies include An efficacy trial of a group-based, culturally congruent intervention to reduce HIV risk among recently incarcerated, bisexual African-American men An exploratory, a mixed-method study on people who initiated drug injection in their 30s -An evaluation of substance abuse prevention interventions in Los Angeles County -A community-based participatory research project to reduce multiple health risks among middle-school-aged Latinos and their parents Previously, Dr. Bluthenthal has used quantitative and qualitative research methods to establish the effectiveness of syringe exchange programs, test novel interventions and strategies to reduce HIV risk and improve HIV testing among intravenous drug users and men who engage in same-gender sexual encounters.


– [Kijuana] Hello and welcome to the Master of Public Health online program’s Hot Topics in Public Health webinar, presented by the Keck School of Medicine at the University of Southern California. My name is Kiana Lloyd, I am an enrollment advisor for the Master of Public Health online program, and I’ll be your host today. First, I’d like to thank you for taking time out of your busy schedule to join us. Before we begin, I’d like to review what you can expect during the presentation. To cut down on background noise, please mute your phone line so as not to disturb the presenters. If you have any questions for our speakers, please type them in the Q&A box in the lower right-hand corner of your screen and hit send. Feel free to enter your questions as you think of them, and we’ll answer as many as time allows at the end of the presentation. A copy of this recording and slide presentation will be available shortly after. And please follow us on Twitter @USConlinemph. Here’s a quick look at what we’ll be covering today. First, you will hear from our program director, Dr. Shubha Kumar. Dr. Kumar will speak to the Keck School of Medicine of USC and she will introduce our speaker. Lastly, we will end the presentation with a brief Q&A session. Now, let’s begin. Dr. Kumar, thank you for joining us today.

– [Dr. Kumar] Sure, thank you Kiana, and thank you everybody for being here today and taking the time out of your schedule. I’m Dr. Kumar and I oversee the online MPH program. My background is in management and leadership in global health and development, as well as program planning and evaluation. And we’re quite excited to be able to have this event today and hear from Dr. Ricky Bluthenthal who is one of the nation’s leading experts in the area of drug injection. I will share with you a little bit more about the School of Medicine before getting into the presentation from Dr. Bluthenthal. So, we are located within the School of Medicine at USC, and Keck was established in 1885, we’re actually the oldest medical school in Southern California, and we are affiliated with several leading hospitals and research institutes and do a lot of patient care, as you all know. The Department of Preventive Medicine is located within the School of Medicine, and that’s where our MPH program is housed. In terms of our department, we have six divisions ranging from global health, biostatistics, cancer epidemiology, as well as health behavior research and more, and we are also affiliated with several institutes that provide cutting edge research in this area, including the Institute for Global Health, and the Institute for Prevention Research, which Dr. Bluthenthal is a member of. At this point, I would like to turn it over to Caroline, who is our student MPH representative to the public health student body, as well as our student advisor to the Keck School of Medicine, and she’ll share a little bit more about this initiative and Dr. Bluthenthal’s background. Thank you.

– [Caroline] Thank you, Dr. Kumar. Welcome faculty, students, and prospective candidates and alumni. I’d like to take a few moments to thank you for joining us today for this amazing learning experience, and as your MaPHSA executive board member, and also your MPH online student ambassador, it is my responsibility to help seek out events that represent our students’ interest. USC MPH students are extremely interested in our nation’s opiod crisis and they to learn more about how to address this issue as public health professionals. With the CDC’s March announcement of a national 30% increase in overdoses from 2016 to 2017, this discussion could not be more timely. It is an honor to introduce today’s hot topic speaker and educator, Dr. Ricky Bluthenthal. He is not only faculty in our preventative medicine department and MPH program, but a research expert and authority on our nation’s opiod epidemic. We are very fortunate to have him as one of our professors. And please join me in welcoming this amazing guest, we are sure to learn to a lot from him. Welcome Dr. Bluthenthal.

– [Dr. Bluthenthal] Thank you for those kind words. Why don’t we get started? So for 25 years, I’ve been conducting research on health issues related to injection drug use. I began with a response to the HIV epidemic. And I’ve stuck with it long enough to now be dealing with this new challenge to public health for people who use drugs, which is the opioid crisis and attendant overdose death, and other health ailments that I’ll discuss in more detail later on. So let me just get started. So I’ll talk about how we ended up with this prescription opiod epidemic or crisis, I’ll talk about the health consequences of it and then I’ll provide some recommendations about how we might respond to this nationwide crisis. And let me just make a point that I started with HIV, in the United States, HIV really was relegated to cities in large measure. And I’ve obviously had an outsized impact on men who have sex with men and to a lesser extent, people who inject drugs. Although, certainly in the Northeast, there was a substantial HIV epidemic among that population, too. Part of what distinguishes the prescription opioid epidemic from prior crises is that it really is impacting all of us in all kinds of different settings, the rural, urban, suburban, white, black, Latino, Asian, no one is immune to the consequence of this, and I’ll begin to explain why that’s the case. So the opioid epidemic basically has three, it’s a three-legged stool, the first leg of the stool was a change in medical practice related to pain. In the early ’90s it was widely conceded that physicians were under-treating pain. And so there was an effort led to sort of change that. So physicians became more interested in treating pain. Now, that created some, in sort of this idea as pain as the fifth vital sign, and that created some unintended consequences. So one of which is that pain is very subjective. So we all experience it differently, we could have the precisely same injury and have widely different assessments of how much it hurts. And there’s not a great understanding of that. Another problem with pain is that typically when someone’s prescribed a pain medication, if there’s a problem, the recommendation is sort of give them more of that pain medication. In the face of the sort of new opioid medications, that becomes a real problem. And then finally, there was a real move away from just using opioids to treat acute pain, and so you might think about that, if any of you’ve had your wisdom teeth taken out, you were probably given an opioid kind of pain medication, and they’re great for treating acute short-term pain, that’s why they’re widely used in the military when people are shot or injured. But the move of them into chronic pain created a whole separate set of problems. So that’s one stool, pain is a fifth sign. The other was new technology. So pharmaceutical companies developed these long-acting opioid medications, so the typical opioid medication will last four to six hours, these new formulations were advertised as lasting eight to 12 hours, which has some modest advantage, you’re sort of taking fewer pills, but I think it’s now well-documented both in popular literature and in the scientific literature that they’re not necessarily that long-acting, and some of that just relates back to the issue of pain being a subjective kind of phenomenon. Regardless, they really didn’t go to the trouble of establishing that these long-acting approaches were superior to the short-acting formulations. The abuse potential for these medications was not established before they became widely distributed. And in fact, the manufacturers claimed that they had low abuse potential, which we now obviously know is not true. And then the other piece is that when you use these medications outside the context of either chronic or acute pain, the euphoric effects are substantial. So they make you very high, to put it a different way. And so they’re highly desirable as a recreational drug. Then the third leg is pharmaceutical marketing. These are large, multi-billion, large companies, global in nature, billions and billions of dollars of annual revenue and profit. So their capacity to make sure that these medications were widely available to anyone who might possibly need them are really impressive. In the case of one of the manufacturers, there was a successful effort to target physicians, and it began by focusing on physicians with high rates of opioid prescribing. They were spending enormous amounts of money marketing these medications to physicians. In one case, a company spent over $200 million on that. In another year, they reached 90,000 physicians in the United States. Because the distribution system is through medical care, it’s sort of available in every zip code, or many zip codes. And then lastly, this again, this shift away from acute pain to chronic, which is driven, if you’re a pharmaceutical manufacturer, there are real advantages, a lot more people with chronic pain than acute pain. And so that shift to using these medications for chronic pain sort of created the circumstance that we’re in. So this chart just shows you the massive increase in prescription opioid availability in the United States. So the way I think about this is essentially, what we’ve created circumstance of is that for anyone who might misuse opioid prescription medications, they’ve probably had a chance to do so. That could happen through diversion, so someone in their family gets those medications, and doesn’t use all of them, so there’s some left in the medicine cabinet, and they begin using that way. That could happen from people who have an acute or chronic pain injury who begin to misuse, as a way of managing both the pain, or of achieving highs. And it’s worth pointing out that one of the challenges with these medications is if you continue to have pain, that we’ll prescribe higher doses, which will facilitate this sort of process of becoming physically dependent, which is sort of a unique quality of opioid medications. So if you stopped using them, you feel very sick or unwell. And then the other piece of it is that, so some patients became misuser from sort of this escalation of treating their pain. The other thing is that if you take these medications for a long time, you can develop a condition called hyperalgesia, which makes you really sensitive to pain, so you’re sort of caught up in the cycle of, you’re hyper sensitive to pain, so you start off, you had a pain problem, the medications perhaps dealt with it or didn’t deal with it, you took more of it, you’re now physically dependent, and then you’re even more sensitive to pain, so your desire to take more increases even more. So those are the conditions that sort of have emerged for us, and as a consequence there’s been a response. So one of those responses is development of these abuse-deterrent pill formulations, and the goals of those medications are to not allow you to break the pill down, the reason why people would break the pill down is that if you take a long-acting pill and say, crush it to snort it, or liquefy it to inject it, the euphoric effects are substantially greater. So you get a, for one of the better terms, a better high. So we’ve had the introduction to these pill formulations to work against that, although, you know, they’re not, they’re available now, they’re in use, but they’re still, the old kind are still available. There’s not prescription drug monitoring programs in most states, and what that basically is is a repository of all prescriptions given to people. And what it allows physicians to do is if they have a patient in front of them for whom an opioid medication might be indicated, they can look into this prescription drug monitoring website and determine whether the person already has outstanding medications for that. So it’s a way of deal with the issue of doctor shopping and sort of drug-seeking in various medical facilities. The other thing is the FDA and cities and states have actually successfully sued prescription opioid makers in a variety of settings, but owing to some of the changing political dynamics in the United States, so settlements have tended to be on the smaller side, and certainly, the last case I looked at, I think a manufacturer agreed to pay West Virginia $25 million. But they’re making billions of dollars on the sale of these drugs, so a $25 million fine here or there is not gonna stop them or deter them. So beginning since 2011, we’ve had this sort of substantial decline in opioid prescribing. The President the other day indicated that he’d like to see that drop another 30%. Which sounds well and good, but there’s some problems with sort of rapidly removing these medications from circulation, now that everyone has sort of been exposed to them. So this chart shows you sort of, this is from the National Household Survey, National Survey on Drug Use and Health, shows you past year initiation, past year misuse, and past year disorder for prescription opioids, which are in the blue and heroin, which is in the red. And they key point here is we’re sort of in a pickle now. So we’ve exposed lots of people, two million people initiated prescription opioid misuse in 2016, another almost 200,000 initiated heroin use. We have nearly 12 million people with past year prescription opiod misuse, and nearly a million heroin misusers, and then high numbers of people with opioid use disorder and heroin use. So one of the things that’s gonna happen as we pull back the legal, the availability of the legal medications is that people will begin to move into illegal substances. So we’ve seen, if you just look at the last bullet, a five-fold increase in the number of heroin users in the last decade, and the reason for that is that heroin is pharmaceutically similar to prescription opioids, it’s also less expensive in illegal markets, so in Los Angeles, for instance, you can buy what’s effective a dose of heroin for $10, whereas buying a prescription opioid would cost between $30 and $90 for them, depending on the amount of, the milligrams of opioids in the particular pill. Heroin is now widely available in urban settings and is increasingly available in suburban and rural settings to match the market demand that’s been sort of created by these, by the pharmaceutical drugs. So, these are, we have a couple of reports, we don’t have great data on this, and we don’t have really good surveillance that allows us to understand transitions between drugs, so even the National Household Surveys cross-sectional study, there are relatively few local cohorts of non-injecting drug users that we can sort of follow and see how many people are transitioning from opioids to heroin or from heroin to injection. Here’s some of the data that’s available, at least on that on that first point of movement of people from prescription misuse to heroin use, so the first study saw about four percent movement in five years, Carlson’s was the most recent study from Ohio found among prescription opioid user about three percent of them became heroin users. And the Surratt, looking at a group of club drug users, many of them were men who have sex with men, saw an annual uptick of seven percent. So the thing to think about though, is if that translates into a real number at the population level, so if there are 12 million people with prescription opioid misuse, seven, five percent of them moving into heroin use is a substantial number of people, it’s hundreds of thousands of people. So, that’s gonna continue to be a challenge for us moving forward. So, injecting heroin, similar to injecting prescription opioids, creates a better high, there’s some forms of heroin, so the heroin that’s available west of the Mississippi tends to be black tar heroin, so it’s more difficult to use without injecting, and we also know from the National Household Survey that of the people who use heroin, half of them inject it, and that compares to 13% for meth users and cocaine users. So, the sort of premise is that we have all these things happening, we have an overdose epidemic, I’ll show you data on hepatitis C and HIV outbreaks, there are a variety of other ailments coming with that. But we also have, which has not been talked about, an emerging injection drug use epidemic that’s gonna have substantial public health consequences. So the way we’ve looked at this is using local data from San Francisco, Los Angeles, this is based on sort of two studies I’ve conducted in the last eight or nine years, one’s a cross-sectional study, that was the first one in 2011-13, and then I have a cohort study that’s ongoing now. And what we’ve tried to do is sort of bring in some, what I would call, sociological context into understanding drug use patterns. So the first one is this sort of idea of drug use generations. And if you sort of surveyed drug use patterns in the United States, you would see an evolution of people moving away from heroin in the ’60s towards cocaine, and then from cocaine to crack cocaine in the ’80s, from crack cocaine to meth in the ’90s and 2000s, and then from meth to this prescription opioid stuff, which is sort of in the, really took off in the 2000s. And that’s sort of the current place we’re at. And that’s useful to think about ’cause one of the underlying principals of drug misuse is that if you’re susceptible to drug misuse, you end up using the drugs that are available at the time. And the implication of now having this opioid be the main problematic illicit drug has real consequences because opioid users tend to use for years, not in decades, not months and years, which kind of characterize the crack, the cocaine, the crack cocaine, and even to a lesser extent, the methamphetamine cohort. So people will start, they’ll mess around with it for awhile, but typically they’ll age out of it, or their life circumstances will change and they’ll move out of it, or they’ll get burnt out. We know from the earlier generation of heroin users that came out of the Vietnam War era, those folks continued to use for 20, 30, 40, 50 years and that’s what we’re looking at now. So we’re gonna have a problem that’s gonna go on for a long time. So using this idea about drug use generations is helpful in sort of contextualizing the implications of the change from meth to prescription opioids. The other thing we do is we use this Drug, Set, and Setting model, which again sort of underscores the need to look at the pharmacokinetic attributes of the drug and how that impacts use patterns, and I’ve sort of already described that to you. And then finally, life course theory is helpful in looking at how people age or don’t age out of drug use and then how they remain vulnerable. And one of the early warning signs of the prescription opioid crisis was the fact that you saw older people requesting substitute, medically-assisted treatment or opioid substitute treatment in different demographic groups And that’s unusual, typically if we’re gonna misuse drugs, we will misuse them through our 20’s, but most folks age out of it. And so, when you begin seeing 40 and 50-year-olds requesting treatment for methadone or buprenorphine then you know that you’ve got a different, you’ve changed the life course framework of drug use in the United States. So I’ve sort of briefly described the studies, the first one is cross-sectional, the second is the cohort study we’re in the midst of still collecting our six month to 12 month data for that. So the characteristics of my sample, mostly male, little less than 15, 15 to 20% gay, lesbian, or bisexual, mostly white but with decent representation of Latinos and African-Americans, the population I see is largely homeless and one of the next things I’ll be working on is this big jump in the prevalence of homelessness, which went from 60% in the 2011-13 sample to over 80% of the 2016-17. And then we’re also seeing basically a doubling of younger people between the two studies. So part of what we’ve done with this work is just begin to map on that this population of people who inject drugs actually can give us a window into understanding national drug use trends. And so this slide just sort of is my attempt to sort of match those two things. So what you see is the proportion of the sample that report using this drug for the first time by half decades, and you see we have a heroin peak in the late ’60s, that’s then replaced by cocaine peak in the late ’70s, and then a crack cocaine peak in the late ’80s, and then meth jumps up and then you see meth being surpassed by prescription opioids going into this last period of 2005 to 2009. So, I think this sort of makes the case for saying, yeah, it’s reasonable to use this kind of sample, using their retrospective reports to sort of understand national drug use trends. So the first question is, what are the implications of having prescription opioids be the sort of the main illicit drug that people are using now? And this shows you that change. So one of the implications is the move of prescription opioids from being relatively infrequent initiator of opioid use, most folks start in the ’80s, and so what this shows you, and I’ll try and explain it, it’s a little bit complicated, is the first column, the pre-’60s generation, so this shows that about 12% of them or 15% of them started their opioid use with prescription medications, and then most of those started with heroin, which is this middle one and then at the same age. And then if you just look at the first bar in each column, you see it grow substantially. So by the 1980’s, nearly 70% of people, their first opioid is the prescription drug, or they’re using them in the same year, which is the one on the far right. So, that’s a big change and part of the implication of that is, again, heroin is not widely available, although increasingly it is. Prescription opioid are everywhere, and so that’s what sort of driving this, is that you get this sort of generational switch in drug use patterns. And this is sort of another way of representing this. Now, this is looking at the first drug injected. And what we see here is the top line is heroin, and the bottom line is cocaine or meth. And so again, reflecting the certain drug use patterns, the first drug injected was increasingly a speedy drug, so cocaine or meth, but then as these new cohorts come on, we see it begins to go down, and instead we have heroin becoming the first drug we inject, and if we drew another line out for the ’90s, we didn’t have a lot of people in the sample who were born in the ’90s, but the number continues to go up, so we’re gonna have more heroin injection as a consequence, as a sort of follow-on from the prescription opioid crisis. So then the next thing, again, trying to make the point about how opioids leading to heroin leading to injections sort of changes the injection drug use epidemiology in the country, we sort of developed two measures, one of them is, one is sort of the time to injection, and that’s a broader measure focused on how old were you when you first used an illicit drug, and then you first injected any drug, so that’s just one measure of time, that’s one time to injection. And then we have a second one that asks the question, when you first used any drug, how long was it before you injected it? And all of this, the take home for this will be largely that the uptick of heroin means that we’re gonna end up with a lot more injection drug users moving forward. So just looking again, remembering that we had this change of people using more heroin injection, this is an overall time to time from first use to injection by birth cohort again, and you see it was pretty low for the pre-’60s generation, that was mostly exposed to heroin, and then went up with cocaine and crack cocaine, and now it’s going down again. Then, we’ll be able to look at this in my new sample, which as many more people born in the ’90s, but I would expect that the bars for the folks born, the age cohort born in the 1990s would be even shorter. And then this just sort of looks at that using multi variant regression, it’s a linear regression model with time to injection as the dependent variable. And the key thing here is we just look at the bottom two rows, we see there’s a negative number with the 1970’s as a reference, and what this indicates is that folks born in the ’80s were significantly, had significantly shorter times to injection as compared to folks born in the ’70s, which sort of reinforces that point. So then we use survival analysis techniques to look at time from first use to first injection, and again, this sort of shows this unhappy story with heroin users median survival time is a little more than a half of year. So from your first use of heroin to your first injection, less than a year. It’s over a year for speed, and then much longer for cocaine and crack cocaine. And then within 10 years of first use, 93% of the heroin users will have injected, as compared to 78% for meth and 70% for cocaine users and then 30% for crack cocaine users. And then last, this is just a representation of the data again, and the point of this is just to show that a lot of that action really is in the first year. So the slopes on these lines are not significantly different, but what is different is the entry point. So that first year of use, seems to inevitably lead to injection for most heroin users. So the opioid epidemic is associated with more rapid transitions to injection drug use, and that people using heroin, which is the drug that sort of follows on naturally from prescription opioids are gonna end up injecting. All right, so one of the problems with having more injectors is that, in a way, injection begets additional injection. And so let me explain what I mean by that. So we conducted that initial study, 2011-13 was a study on how people, basically asked the question, how do people become injection drug users? And what we found that it isn’t a, it’s a process, it’s a social learning process. So folks, the story that people told us about their pathway to injection involved exposure to injectable drugs, being around people who injected drugs, an opportunity to receive instruction in injection, and then actually getting assistance injecting. Most of us don’t like getting shots, we’re needle-phobic, it’s difficult to hurt yourself intentionally, which injection requires. So basically, 70 to 90% of the people who ever inject need help injecting that first time. And so this social learning process sort of summarizes that process, so we’ve asked questions of people like, do they encourage others to inject drugs, do they inject in front of non-injectors, do they describe injecting to non-injecting, understanding that these are potentially precursors to injection drug use for non-injectors. And what this shows you is that these precursor behaviors are associated with initiating people, so if you’ve ever described injecting to someone, you’re more likely to have initiated someone in the past 12 months. We also looked at whether you’re being asked, and that sort of is a good measure that the person who currently injects is sort of involved in that social learning process, and what this basically just shows is that when you do these precursor behaviors, when you inject in front of non-injectors, when you describe injecting to non-injectors, or when you do both, you’re gonna be much more likely to be asked to initiate someone for the first time. And this just sort of is a figure that sort of shows that again. The bottom one is ever initiated someone, if you’re not injecting in front of non-injectors, if you’re not describing it, if you’re not doing both, you’re very low probability of initiating someone. Either in the last 12 months or ever, which is the middle line. And then you see the thing about being asked, which is the top line. So one of the things that’s disturbing, we know that heroin use is increased based on the national surveys, the data that we’ve collected in San Francisco and Los Angeles indicates that injection, both from the changes in the demographics of our sample, but also in the self reports from people who currently inject, it looks like there’s more initiation going on. So you can see, these are comparing the 2011-13 samples to 2016-2017 sample, recent initiation was seven percent in the earlier sample, it’s 13% in the newer one and we changed the question. So the question in the newer one is for the last six months. So that number, if it was annualized, would probably be higher. Describing injections gone down, but injecting in front of non-injectors has gone up, and that probably has something to do with the increased homelessness. And then a willingness to initiate people in the future is basically equivalent. So just so you know, I am trying to do something about that, and my current study, this sort of second one is a short hour-long active listening, motivational interviewing, intervention with current injection drug users to sensitize them so the risks of the precursor behavior and then to provide them with behavioral skills and role playing opportunities to sort of figure out how to get out of those situations if they find themselves in them. So what are the consequence of all this? They’re relatively horrific. In 2015, Scott County, which has about 40,000 people in it, had an outbreak of HIV and hepatitis C among the people who inject drugs there. They had 183 infections in a year, just to give you an idea, L.A. County, which has 13, 14 million people in it had 56 injection drug use related HIV cases in that same period of time. So 40,000 people with 183 HIV infections, just 56 with 13 million people. There are documented outbreaks of hepatitis C in Kentucky, Tennessee, Virginia, and West Virginia. Most of those cases now, because we have a cleaned up drug supply, are gonna be from injecting drugs, so sharing syringes or sharing cooker’s cotton, or other drug use injection paraphernalia. HIV incidence has increased among young people in nonurban counties. We’ve seen dramatic increases in abscesses, so skin, the soft tissue infections that are often associated with injection drug use, we’ve had these increases nationally and in North Carolina, a hospitalization for infective endocarditis related to drug injection. We’re seeing this age cohort difference now. So acute HIV, excuse me, acute hepatitis C rates have increase among young adults. And so the difference between acute hepatitis C case or chronic is that acute case is new. So those are folks who’ve been infected in the last six months, dramatic increases after the long-standing declines among all populations. Again, that tracks with increasing evidence of more drug injection in the United States. This is data from California showing the age distribution of chronic hepatitis C cases, so we went from having a nice little bell curve or one hump camel to now emerging to have a two hump camel as younger people begin to increasingly become infected with hepatitis C. And then you can see, this is some representation, if it’s darker means more hepatitis C, and this sort of underscores again the almost global impact or it’s sort of hitting everywhere. So we have increases in Los Angeles, the quintessential urban community in California, increases in the Bay Area, but also increases in these sort of rural areas in northern California where folks are moving or getting, have been exposed to prescription opioids or misusing them through injection or perhaps transitioning to heroin if that’s available in their local communities. And then we’ve all talked, there’s been a lot of talk about the overdose deaths. So there’s sort of two qualities of this. Earlier I made the point about as we pull back prescription opioids, we do run the danger of people moving to the illegal alternatives, that’s happened, so you see this reflected in the heroin overdoes deaths beginning in 2010 how they’ve gone up dramatically. And then the thing that began to happen in 2013 is that the heroin supply became contaminated with synthetic opioids, the main one being Fentanyl. This is a problem because Fentanyl is 10 to 50 times more powerful than heroin, so the risk of overdoes increases dramatically. And that sort of, it’s a sort of contamination thing. So folks don’t, this may change, but at the moment for instance, in Los Angeles, folks aren’t buying Fentanyl, they’re buying heroin, but it’s been contaminated with Fentanyl, and this is sort of happening throughout the country. So we have these HIV, hepatitis C outbreaks, we have the overdose crisis, the contaminated drug supply, increasing drug injection and a treatment system, in the 25 years I’ve been doing this stuff, that has not increased to match the problem. And so we’re poorly prepared to deal with this. But we do have lots of options. So let me just start with the first principle, which is that we need many approaches, not just one. And as you follow this debate in the newspaper or as you talk the local decision-makers, or state decision-makers, or your national decision-makers, keep in mind that there isn’t one solution to this. So we’re gonna need to sort of open the full box and take a look at all kinds of different options. So this was a cascade approach that we developed, we weren’t able to test it, but a couple colleagues of mine, Pete Davidson, who’s at UC San Diego, Shoshanna Scholar who now works for the LA County and Carl Castro who runs our military health center at USC, we put this together just looking at this, and the idea is just to highlight the different kinds of choices, if you’re trying to deal with diversion, you might want locked cabinets or lockable pill boxes. If you have patient-driven diversion, you might want to use peer referral to injection drug use to people, or to drug treatment, rather. If people are selling them, you might want to give someone a job so they don’t have to sell drugs instead. If they’re self medication, get them additional treatment. Provide them with overdose prevention training or naloxone. And then referral to drug treatment. So there are lots of things to do, I’m just gonna take you through a little bit of the laundry list of what some of those things might be. So we can do demand interventions to prevent injection initiation. So part of that would be making drug treatment more widely available, but there are some sort of cognitive behavioral interventions, one that Don Des Jarlais did back in the ’90s that sort of tried to arm current non-injectors with the information about how to, about why they don’t want to become injection drug users. There’s this combined structural interventions that Daniel Werb, who’s at UC San Diego and the University of Toronto is exploring which looks at combinations of drug consumption rooms, increase medically assisted treatment, housing first, and decriminalization of illegal drugs. We can do what I’m doing with the existing population of injectors and try and move them away from facilitating injection uptick, and I’ve already described that to you. The middle bullet is the one we’re doing, which is change the cycle. Now, obviously naloxone distribution is very important. Peer drug users and drug injectors are among the most effective respondents to overdose. They know what it looks like, if you arm them with naloxone, they’ve shown over and over again, they’re more than happy to use it and it probably been very effective and we’re collecting more and more data about this, about how effective this sort of approach has been to preventing overdose deaths. And then we spread first responders now, obviously our paramedics have been carrying naloxone for years, but now police are increasingly carrying it as well. You see this just shows the rapid uptick now in distribution of naloxone in the country, so it’s an important development. So here, we used the data again from our 2011-13 sample, 2016-17, so the lighter is the later one, and then these are broken out by city. And the key thing here is just to note that we an increase in overdose between the two samples, probably in part because of the Fentanyl contamination. Many people injects drugs witness overdoses, so they’ve gone up dramatically in Los Angeles. But most importantly, we’ve also increased the naloxone distribution, and so it went from being used four percent of the time when someone observed an overdose to almost 70% of the time. So this shows you the power of drug users to be health interventionist in the midst of this particular crisis. And the same thing that’s happened at San Francisco. San Francisco had a little higher baseline of naloxone distribution, but you know now, 90% of the witnessed overdoses, someone in the community is reversing that with a naloxone, which is a tremendous health benefit. The other hot topic is the safe injection rooms. They’ve accomplished a variety of things. So there are about 100 in the world, no one’s ever died in one of them, I’ve visited probably four or five of them over the years, they serve as clean, well-lit places to use drugs, they’re very effective at preventing overdoes deaths, they’ve been documented to provide a great avenue into services, including substance abuse treatment and housing. They obviously, because people are using alone, reduce any risk of HIV or hepatitis C transmission because the setting is clean, you should see declines in the infective endocarditis, and abscesses. And then finally, because people aren’t using out in the community, they’re using the facilities, that reduces the socializing aspect. In fact, in Switzerland, they have had safe consumption sites for many years since the ’90s, and in fact to heroin prescribing and have seen a dramatic decline in their population of drug injectors because the current cohort of people who use don’t use in the community, they use in this facility and so they’re not in a position to socialize others into that kind of use. Of course, we need to expand treatment dramatically. There are a whole set of regulatory and legal impediments to that that we need to overcome. In fact, I was having a conversation with a pharmaceutical manufacturer earlier today and learned of a new way in which we sort of prevent ourselves from making these evidence-based treatments as widely available as they need. For me, the gold standard really has to be that we need to make legal treatments or substitutions as readily available as the illegal drugs are, and less expensive than them. So right now in Los Angeles, it’s a lot easier for you to get heroin than it is for you to get drug treatment, and we need to change that. And this just sort of underscores our point, we’ve had, there’s been great progress in improving methadone availability and buprenorphine, but if you refer back to my earlier slide, remember, there are almost two million people last year that had prescription opioid disorder and another 600, 700,000 that have heroin use disorder and there are only 400,000 methadone slots. Similarly, there are only 55,000 buprenorphine slots. So that capacity is insufficient to meet the demand that we have. And then this is just a little list of different things we can do, and how they deal with this sort of downstream consequences of the opioid epidemic, including drug injection, these HIV outbreaks, overdoses and fentanyl. There are a lot of things that we can do and we need to move on it quickly. What I’d like to see and what I would have like to have seen yesterday when the President was addressing this topic is a response like we saw of the AIDS epidemic where billions of dollars were put into the fight to develop new medications, to provide preventative services to make sure people have access to care, and we’ve made tremendous improvements in that. HIV is now a chronic ailment, most people, certainly in developed countries, received care. Many people in developed countries now receive care and that sort of what we need to look for in terms of the prescription opioid crisis. Let me just conclude by acknowledging funding from the National Institute of Drug Abuse, our project officers, my best friend and collaborator, Alex Kral, and then the community participants, research assistants, students at USC who have all contributed to this work. Thank you for your attention. We’ll do questions now?

– [Kiana] Yes, thank you Dr. Bluthenthal for sharing that information. We will now try to answer your questions. To submit a question, please type it into the Q&A box in the lower right-hand corner of your screen and hit send. Dr. Bluthenthal, he shared a lot of very important information with us and he’s happy to answer any questions that you have. We do have one question right now, Dr. Bluthenthal. One of our attendees asked, can you briefly describe a little bit more about the pharmacogenomics and the opioid epidemic and where are we with that?

– [Dr. Bluthenthal] Probably not. I’m not sure what pharmacogenetics are.

– [Kiana] I’m so sorry, the pharmacogenomics and the opioid crisis.

– [Dr. Bluthenthal] Yeah, I don’t know what that is. So tell me what that is and then I will try to answer it. Sorry.

– [Kiana] Okay, no problem. We will move on to our next question. Our next question is, what’s considered abuse of opioid use if an individual’s tolerance is higher than average users?

– [Dr. Bluthenthal] Yeah, I think basically there are a couple of definitions of addiction out there. Typically it means, for want of a better term, repeated use with negative consequences. So you’re using so much that you can’t do the normal things that you would typically do. So you can have situations where someone is dependent on an opioid, but it not be addiction. And so cases like that might include folks who are terminal cancer patients, and so they’re taking it for pain relief for the cancer, they’re dependent on it, but it wouldn’t be considered addictive behavior because it’s used to sort of deal with this sort of end life moment that they’re going through. The issue is really, what are the other things happening around you that lead to negative consequences, whether it be driving high, or missing work, or selling your toaster. So here’s one, so how does genes, so this is the pharmogenetics, thank you Ridell. So how does that effect a person’s response to drugs? So thank you for clarifying that. You know, I do not know the answer to that question. Let me just tell you what I think generically about genetic explanations for substance abuse. Which is that I’m sure that there is some contribution and we know that there’s some genetic markers, for instance, for alcohol, and we know there’s some genetic predispositions that certain populations have that make alcohol use more problematic for them. Those probably do exist for opioid medications as well. I’m a sociologist, the part of the problem I’m focused on more is the other dynamics, which is that regardless of what your genetic profile is, if you’ve been exposed to these drugs and you begin to misuse them, we do have relatively consistent outcomes from that and the genetic contribution to that, as far as I know, is certainly not well understood. Should I just keep going through the list? Jennifer Yang–

– [Kiana] Sure.

– [Dr. Bluthenthal] Can we treat opioid abuse as a chronic disease? Well yeah, it is a chronic disease, that’s for sure. I think one of the ares that people are gonna really begin focusing on is that pain is a chronic ailment and we need to come up with other ways of treating pain that don’t involve prescribing folks drugs that are highly addictive. Should I just keep going guys?

– [Kijuana] Absolutely, Dr. Bluthental.

– [Dr. Bluthenthal] Okay, and then there’s a question from Douglas about what are your thoughts on how the opioid epidemic affects state and federal public health policy for treatment conditions are concerned? Okay, so I actually learned something about this today. So I will try and share this with you, and there are a couple of thoughts related to it and I’ll end with the thing that I learned today. Okay, the first thing, one of the problems that we had, I talked about medially assisted treatment, so that’s methadone and the buprenorphine, those are the two main medically assisted treatments. They’re highly desirable because they really are effective. So people who use these medications, their use of illicit drugs go down substantially, there are great benefits in terms of employment and housing and their ability to have lives that look like they don’t have any drug use history. So they’re really powerful that way. Unfortunately, they’ve also been heavily regulated. There have been changes most recently in the legal status, who can prescribe. So for instance, there was just a new directive that came out a couple of months ago from the federal government that now allows nurse practitioners and physicians assistants to also prescribe buprenorphine, so that could be very helpful moving forward. Now one problem is, so we have this Medicare system and Medicaid expansion, and we also have parity, so substance abuse, which is a mental health illness should be treated the same way as a broken arm, in terms of availability of treatment, but there is a thing that sort of happens behind the system that gets in the way of that. So this is the new thing I learned, so there are these things called pharmacy benefit management organizations that basically create the pharmacy formularity so that the drugs that a provider can use to treat X, Y, and Z. And because of market dynamics in that system, some of the best kinds of and most innovative substitution mediations actually aren’t available through people’s health insurance. And the example I learned of today was this drug, this buprenorphine alternative called Bunavail, which is a suboxone, and so it’s a buprenorphine medication that you use as a film, so it’s just like a little piece of paper that you ingest, has lower side effects, but it isn’t widely available because the manufacturer of them hasn’t been able to get through the pharmacy benefit management companies to make it available through insurance. So I think one of the things that we have to look at at both the state and federal level is how do we, it’s gonna be crazy to say this, but how do we deregulate these medications so that they can be made widely available to people that need them because there’s a bottleneck at that level as well. So it’s very hard to get people in drug treatment, like I said, it’s much easier to get heroin than it is to get in drug treatment, and we need to sort of change that. Okay, so in terms of Sy Provost, that’s a great name, asked how do we advocate for more treatments, is it lack in terms of beds or funding? So I think there’s a lack, what would have been great to hear from the President yesterday is here’s a pot of money for evidence-based treatment, states can draw on it as rapidly as they can get patients into these kinds of evidence-based treatment. So there’s the money problem, and then on the other side, there’s a regulatory problem. One thing I did mention is, folks don’t, and maybe in your own communities you’ve seen this, people don’t like having methadone clinics around them, so they can be hard to site. Part of the advantage of the buprenorphine medications is that they’re designed to be given out by primary care physicians, so you don’t end up generating the nimbyism piece, but there are still barriers to making buprenorphine widely available. But yeah, we need more money, we need physician attention and willingness to address this problem. We need folks to understand all the multiple barriers to drug treatment entry that they have. I mean, another issue that’s current in the population I see is that generally speaking, methadone doesn’t have a great reputation among heroin users and many people think of buprenorphine as very similar to methadone. And in fact, it actually isn’t in that it’s a longer acting, it has much less abuse potential or diversion potential if we’re naive people, and it doesn’t have, it has what’s called respiratory sealing effects, so it’s pretty protective against overdose, so figuring out the policy solutions that allow these mediations to be prescribed through insurances and paid for and then dealing with the sort of barriers to use among people with the substance abuse problems, it would be another thing to look at. So can we abuse the treatment? Yes, we need more treatment. And then Jennifer Yang, yeah more integrative care team, sure that’s not a bad idea, but I do want to emphasize again what I see. So if we go back to the slide where I presented the demographic characteristics of the population, 80% homeless, right? So we need a system of care for them that’s gonna make it easy for homeless, chronic drug users to get the healthcare they need. So it’s less of an issue of when they get into the system, if the care team’s integrative, that’d be great, but we can’t get them into the system at all. And so there’s a lot of untreated people who I know from my many years of doing this work would be happy to receive treatment, we just make it really hard for them to get it. And so we really need to rethink how we provide care to this population and think about it in terms of what are the lowest, what’s the lowest, easiest way we can make it for them to get these life-saving medications? So I think I’ve answered the questions that have been listed. Are there others?

– [Kijuana] I don’t see any others, Dr. Bluthenthal, so thank you so much for answering all of those questions for us this afternoon, I want to thank you, Dr. Bluthental. I would like to thank Dr. Kumar as well as Caroline for joining us today, and I’d also like to thank everyone who participated in today’s webinar. If you have any additional questions or as a prospective student, if you think that it’s time to apply, please reach out to either myself or one of our other advisors. A copy of this recording and our slide presentation will be available shortly after. This definitely concludes today’s webinar, and I want to thank you again for joining, and you all have a wonderful rest of the day.