HEALTHCARE AND THE OPIOID EPIDEMIC

DAN MUSE, MD

SIGNATURE HEALTHCARE-BROCKTON HOSPITAL

DISCLAIMER

HEALTHCARE AND THE OPIOID EPIDEMIC

BROCKTON ER. MARCH 13,2017

• 25 year old male who just used heroin.

• Stated he had been clean for about a year but relapsed.

• He was worried his grandparents would find out.

HEALTHCARE AND THE OPIOID EPIDEMIC

• Played baseball in college.

• Got “cleated” on his right hand which resulted in surgery and 2 prescriptions of oxycodone with about 60 pills each.

• Still addicted and on heroin several years later.

HEALTHCARE AND THE OPIOID EPIDEMIC

“How many pills do you think you needed

after surgery?”

HEALTHCARE AND THE OPIOID EPIDEMIC

“About 3-4 days”

WHAT ARE OPIOIDS

WHAT ARE OPIOIDS?

• Opioids are sedative narcotics

• They are used in medicine mainly to relieve pain

• At high levels, opioids repress the urge to breathe

• When someone is having an opioid

overdose, they stop breathing and could die

Opioids

Natural Opioids

opiummorphine

codine

Semi-Synthetic Opioids

heroinhydromorphone

hydrocodoneoxycodone

Fully Synthetic Opioids

fentanylmethadone

Hydrocodone OxycodoneHeroin

The Link Between Heroin and Prescription Drugs

MOST COMMONLY USED OPIOIDS

• Heroin Hydrocodone

• Codeine Oxycodone

• Demerol Levorphanol

• OxyContin Tylenol 3

• Percocet Morphine

• Percodan Vicodin

• Codeine Demerol

• Morphine Darvocet

• Fentanyl Dilaudid

• Methadone Opium

• Opium Tylox

HOW DO OPIOIDS AFFECT BREATHING?

Opioid Receptors, brain

Opioid

WHAT IS AN OPIOID OD?

WHAT PUTS PEOPLE AT RISK FOR ODS?

• Mixing drugs- benzos, alcohol & cocaine especially

• Changes in tolerance

• Physical health

• Previous experience of non-fatal overdose

• Variation in strength and content of ‘street’ drugs

MIXING OPIOIDS WITH BENZOS

• Combining opioids with benzodiazepines or alcohol leads to a worse outcome

• Benzos are psychoactive drugs that have sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant, and amnesic actions

• The most commonly used benzos are: Klonopin, Valium, Ativan, Librium, and Xanax

HOW DID THIS CRISIS COME ABOUT?

WE ARE ALL TO BLAME!

PHARMACEUTICALS

THE REAL DRUG CARTEL

FOUNDERS OF PURDUE PHARMACEUTICALS

NEW YORK TIMESMAY 10, 2007

• ABINGDON, Va., May 10 — The company that makes the narcotic painkiller OxyContin and three current and former executives pleaded guilty today in federal court here to criminal charges that they misled regulators, doctors and patients about the drug’s risk of addiction and its potential to be abused.

• To resolve criminal and civil charges related to the drug’s “misbranding,” the parent of Purdue Pharma, the company that markets OxyContin, agreed to pay some $600 million in fines and other payments, one of the largest amounts ever paid by a drug company in such a case.

• Also, in a rare move, three executives of Purdue Pharma, including its president and its top lawyer, pleaded guilty today as individuals to misbranding, a criminal violation. They agreed to pay a total of $34.5 million in fines.

GOVERNMENT

PAIN IS THE “5TH VITAL SIGN”

HEALTHCARE PROVIDERS

80% OF ALL OPIOIDS ARE PRESCRIBED IN THE US!

HOSPITAL ADMINISTRATORS&

INSURANCE COMPANIES

• INCOME TIED TO SURVEYS….....

PATIENTS(CONSUMER)

MCDONALD SYNDROME: “I WANT IT NOW AND I WANT IT MY WAY”

SUBSTANCE

ABUSE

DISORDER

Drug Companies

“Narcotics are safe for acute pain”

Government

Pain Score….”The fifth vital”

Healthcare Providers WE BOUGHT THE

BILL OF GOODS AND FAILED OUR

PATIENTS

Hospital Administrators

&

Insurance Companies

Meet your “matrix” or don’t get paid

Patient

(Consumer)

McDonald’s Syndrome

WHO’S AFFECTED?

EVERYONE!

PALM BEACH COUNTY, FLORIDA 2015

WHAT DOES THIS ALL MEAN?

WE ARE LOSING THE BATTLE!

2015 CDC REPORT ON OPIOID OVERDOSES

• More then 33,000 people died (Just less than 60,000 over 10 years died in the Vietnam War).

• Nearly half died from prescription drugs.

• 91 people die every day from an opioid overdose.

• Since 1999 the number of opioid overdoses and the prescriptions written have nearly quadrupled.

CDC REPORT ON OPIOID OVERDOSES

DEATHS % INCREASE

2014 1289 19%

2015 1724 35%

OPIOID OVERDOSES BROCKTON HOSPITAL

2015

• Number of overdoses: 615

• Naloxone given: 481

• Number males: 421

• Number females: 194

2016

• Number of overdoses: 635

• Naloxone given: 488

• Number males: 443

• Number females: 192

BROCKTON HOSPITAL

NUMBER OF DEATHS

•2015 = 24

•2016 = 17

PERCENTAGE OF OVERDOES NOT FROM BROCKTON

50%

FENTANYL

“the game changer”

FENTANYL

• Fully synthetic (can be made in a lab)

• Fentanyl: 80-100 times more potent then heroin

• Carfentanil: 10,000 times more potent than morphine and 100 times more potent than fentanyl.

FENTANYL

• Comes as a white powder.

• Extremely concentrated that can enter the body by

• Inhalation

• Swallowing

• Absorbing Through The Skin

FENTANYL DISSEMINATION

• AIR: As a power or a spray.

• WATER: Contamination.

• FOOD: Mixed in or on food and swallowed.

• TOPICAL: Absorbs through the skin.

SMALL AMOUNTS CAN KILL YOU

• 2 MILLIGRAMS OF CARFENTANIL ARE THOUGHT TO BE ABLE TO KILL AN AVERAGE SIZED MAN

HEROIN TO FENTANYL

• Carfentanil:

5000x

• Fentanyl: 50x

• Heroin: 1x

ONE KILO OF FENTANYL IS EQUAL TO 50 KILOS OF HEROIN

WHY FENTANYL?

It is a synthetic drug and can be made

anywhere

GOOGLE SEARCH

“How to make Fentanyl”5,580,000 results in 0.68 sec

A CONVENIENT ONE-POT SYNTHESIS OF FENTANYL

“The whole reaction takes place under mild conditions and at room temperature. By performing three successive one pot reactions, separation and purification of the intermediates were excluded, thereby increasing the overall yield. This method can also be used for the synthesis of fentanyl analogues.”

WHY FENTANYL?

It’s concentrated making it hard to find and easy to

transport.

HEROIN FENTANYL

EASIER TO TRANSPORT

DEA REPORT: COUNTERFEIT PILLS FUELING U.S. FENTANYL AND OPIOID CRISIS

Traffickers can typically purchase a kilogram of fentanyl powder for a few thousand dollars from a Chinese supplier, transform it into hundreds of thousands of pills, and sell the counterfeit pills for millions of dollars in profit. If a particular batch has 1.5 milligrams of fentanyl per pill, approximately 666,666 counterfeit pills can be manufactured from 1 kilogram of pure fentanyl.

WHY FENTANYL?

IT’S VERSITILE:

• Can add it to heroin for an extra kick.

• It can be made into pills.

• You can snort it, shoot it, eat it and even wear it!

MIXING THE DRUGS

• Heroin and fentanyl and carfentanil

• Meth and fentanyl

• Cocaine and fentanyl

• Just fentanyl!

ALL THESE COMBINATIONS ARE BEING SOLD AS HEROIN

WHAT DOES THIS MEAN?

• Users are unaware of what they are getting.

• The imprecise cutting of the drug results in

varying strengths.

• Ultimately it means more overdoses and deaths.

RECENT EMAIL BROCKTON HOSPITAL TO POLICE CHIEF

“The 28 year old from East Bridgewater received a

total of 14mg of Narcan, 10 nasal and 4 IM.

Interesting to note his urine tox screen was

negative for opiates. The Narcan worked, so this

leads me to Fentanyl or Carfentanyl.”

THE DOG CHASING ITS TAIL

FURANYLFENTANYL

• A synthetic derivative of fentanyl

• Until recently sold on the internet and produced

in China.

• Depending on the article it is as potent or

stronger than Fentanyl

SYNTHETIC DRUGS

• Legally, no drug is illegal until the DEA investigates

it and then makes it illegal.

• With synthetics, a single chemical change on the

drug makes it new and now is legal until made

illegal.

SYNTHETIC DRUGS

• Synthetic drug Fentanyl is changed and this new one is now legal

• It is made illegal by the DEA and the chemist now …..

• Make another change to the drug making the new drug legal...

• Which the DEA investigates and makes this drug illegal

• Which the chemist changes and makes a new legal drug

• Which the DEA investigates..........................

DOG(DEA/FDA/LE) CHASING ITS TAIL

FIGHTING BACK

MEDICAL COMMUNITY

• Limit the prescriptions.

• Proactively assist those with Substance Abuse Disorder.

• Educate themselves and the patients on pain management and opioids.

• Reach out to the community.

• Support the training and distribution of naloxone.

WHAT IS NALOXONE?

Naloxone is and antidote to opioids.

It knocks the opiate off the opiate receptor

Temporarily takes away the “high,” giving the person

the chance to breathe

Naloxone works in 1 to 3 minutes and lasts 30 to 90

minutes

WHAT IS NALOXONE?

• Naloxone can neither be abused nor cause overdose, only

contraindication is known sensitivity, which is very rare.

• Too much Naloxone can cause withdrawal symptoms such as:

muscle

discomfort

disorientation

combativeness

nausea/vomiting

diarrhea

chills

HOW DOES NALOXONE EFFECT OVERDOSE?

NALOXONE REVERSING AN OVERDOSE

LAW ENFORCEMENT

• Give them the resources to fight the criminals.

• And follow their lead in trying to assist those with

substance abuse disorder.

PATIENTS

EMANCIPATE YOURSELVES.

AND THE GOVERNMENT….

EDUCATORS

• You are the saviors.

• Only with education and prevention can we make

a permanent change.

QUESTIONS?

THANK YOU!

REPUBLICIAN DA CRUZ SHOOTS WIDE TO THE LEFT….

IOWA TRAGEDY