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List of countries by prevalence of opiates use

From Wikipedia, the free encyclopedia

This is a list of countries (and some territories) by the annual prevalence of opiates use as percentage of the population aged 15–64 (unless otherwise indicated).

The primary source of information are the World Drug Report 2011 (WDR 2011) and the World Drug Report 2006 (WDR 2006),[1][2] published by the United Nations Office on Drugs and Crime (UNODC). The indicator is the "annual prevalence" rate which is shown as the percentage of the youth and adult population who have consumed the drugs at least once in the past year. The largest producer of opiates in the world is Afghanistan to a total of 93% of the world's market.[3]

The list does not include opioids, which is classified as a different drug under the World Drug Report 2011 list, which is considered "opiates and prescription opioids."

Rank Country or Entity Annual prevalence (percent) Year Sources and notes
1  Afghanistan 2.65 2009 [4]
2  Ukraine 1.64 2007 [1]
3  United States of America 1.6 2012 [5]
4  Myanmar 1.16 2006 [1]
5  Russia 1.13 2010 [1]
6  Macau 1.1 2003 [2]
7  Thailand 0.94 2009 [1]
8  Seychelles 0.91 2007 [1]
9  Iran 0.9 2012 [1]
10  Luxembourg 0.9 2000 [2]
11  Lithuania 0.9 2001 [2]
12  Uzbekistan 0.89 2006 [1]
13  Estonia 0.81 2004 [1]
14  Italy 0.8 2004 [2]
15  Kyrgyzstan 0.8 2010 [1]
16  Kazakhstan 0.74 2006 [1]
17  United Kingdom 0.73 2012 [6]
18  Croatia 0.7 1999 [2]
19  Laos 0.7 2005 [2]
20  Nigeria 0.7 2008 [1]
21  Portugal 0.7 2000 [2]
22  Georgia 0.6 2000 [2]
23  Brazil 0.6 2001 [2] (12-65)
24  Spain 0.6 2000 [2]
25   Switzerland 0.6 2000 [2]
26  Latvia 0.6 2002/04 [2] (UNODC estimates)
27  Ireland 0.6 2001 [2]
28  Tajikistan 0.54 2004 [1]
29  India 0.5 2001 [2]
30  Malaysia 0.5 2001 [2]
31  Australia 0.5 2004 [2]
32  New Zealand 0.5 2001 [2]
33  Bulgaria 0.5 2001 [2]
34  Albania 0.5 2000 [2]
35  Macedonia 0.5 2004 [2]
36  Sweden 0.5 2000 [2] (16-64)
37  Slovenia 0.5 2001 [2]
38  Austria 0.5 2002 [2]
39  Malta 0.5 2003 [2]
40  Zambia 0.4 2003 [2] (UNODC estimates)
41  El Salvador 0.4 2004 [2] (UNODC estimates)
42  Canada 0.4 2000 [2] " (Ontario, 18+)"
43  Belgium 0.4 1997 [2]
44    Nepal 0.4 1996 [2]
45  Belarus 0.4 2003 [2] (UNODC estimates)
46  France 0.4 1999 [2]
47  Denmark 0.4 1997 [2]
48  Czech Republic 0.4 2003 [2]
49  Yemen 0.4 2001 [2]
50  South Africa 0.3 2004 [2] (UNODC estimates)
51  Turkmenistan 0.3 1998 [2] (Tentative estimates)
52  Armenia 0.3 2005 [2]
53  Angola 0.3 2001 [2] (UNODC estimates)
54  Taiwan 0.3 2002 [2] (UNODC estimates)
55  Vietnam 0.3 2002 [2]
56  Qatar 0.3 1998 [2]
57  Israel 0.3 2001 [2] (18-40)
58  Netherlands 0.3 2001 [2]
59  Germany 0.3 2003 [2]
60  Iceland 0.3 1998 [2] (UNODC estimates)
61  Greece 0.3 2004 [2]
62  Cyprus 0.3 2004 [2]
63  Sri Lanka 0.3 2004 [2] (UNODC estimates)
64  Slovakia 0.3 2002 [2]
65  Bangladesh 0.3 [2]
66  Hungary 0.3 2003 [2] (18-54)
67  Romania 0.3 2002 [2] (UNODC estimates)
68  Kenya 0.2 2004 [2]
69  Somalia 0.2 2004 [2]
70  Bahamas 0.2 2003 [2] (UNODC estimates)
71  Democratic Republic of the Congo 0.2 2004 [2]
72  Azerbaijan 0.2 2000 [2]
73  Chad 0.2 1995 [2]
74  Liberia 0.2 2004 [2]
75  Sierra Leone 0.2 1997 [2]
76  South Korea 0.2 2004 [2]
77  Hong Kong 0.2 2004 [2]
78  Indonesia 0.2 2002 [2] (UNODC estimates)
79  China 0.2 2003 [2]
80  Guatemala 0.2 [2] (UNODC estimates)
81  Panama 0.2 [2] (Tentative estimates)
82  Kuwait 0.2 2003 [2]
83  Jordan 0.2 2004 [2] (UNODC estimates)
84  Iraq 0.2 2001 [2]
85  Chile 0.3 2010 [2] (12-64)
86  Uruguay 0.2 2003 [2] (UNODC estimates)
87  Maldives 0.2 2001 [2] (Tentative estimates)
88  Poland 0.2 2002 [2]
89  Argentina 0.1 2004 [2]
90  Colombia 0.1 2004 [2] (UNODC estimates)
91  Rwanda 0.1 2004 [2]
92  Dominican Republic 0.1 2001 [2] (12-70) (UNODC estimates)
93  Algeria 0.1 2004 [2] (UNODC estimates)
94  Libya 0.1 2004 [2] (UNODC estimates)
95  Kuwait 0.1 2003 [2]
96  Ghana 0.1 2004 [2]
97  Republic of the Congo 0.1 2004 [2]
98  Central African Republic 0.1 2004 [2]
99  Niger 0.1 2004 [2]
100  Japan 0.1 2002 [2]
101  Costa Rica 0.1 [2] (UNODC estimates)
102  Honduras 0.1 1995 [2]
103  Mexico 0.1 2002 [2]
104  Venezuela 0.1 2003 [2] (UNODC estimates)
105  Ecuador 0.1 1999 [2] (UNODC estimates)
106  Finland 0.1 2002 [2]
107  Norway 0.1 2001 [2]
108  Lebanon 0.09 1999 [2]
109  Syria 0.09 1999 [2] (Tentative estimates)
110  Moldova 0.07 2000 [2]
111  Ethiopia 0.05 [2] (Tentative estimates)
112  Uganda 0.05 2004 [2]
113  Antigua and Barbuda 0.05 2000 [2]
114  Turkey 0.05 2003 [2]
115  Bolivia 0.04 [2] (Tentative estimates)
116  Zimbabwe 0.04 2004 [2]
117  Tunisia 0.03 2003 [2]
118  Namibia 0.03 2000 [2]
119  Senegal 0.03 [2] (Tentative estimates)
120  Suriname 0.02 1998 [2]
121  Tanzania 0.02 1998 [2]
122  Morocco 0.02 2004 [2]
123  United Arab Emirates 0.02 2004 [2] (UNODC estimates)
124  Pakistan 0.02 2005 [2]
125  Barbados 0.01 [2] (Tentative estimates)
126  Cote d'Ivoire 0.01 1997 [2]
127  Brunei 0.01 1998 [2]
128  Saudi Arabia 0.01 2000 [2]
129  Bahrain 0.01 1996 [2]
130  Singapore 0.004 2004 [2]

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  • The Opioid Crisis: HMS Responds With Education
  • 19. Aggression III

Transcription

Good afternoon. We want to make sure to stay on schedule. I'm George Daley, the Dean of Harvard Medical School. It's my privilege to welcome you here today for what is an incredibly important discussion on the transformative role that education can and should play in solving one of the greatest public health crises faced by our nation. And that is the opioid crisis. The numbers are heartbreaking, by now painfully familiar. Millions of Americans are struggling with addiction. Tens of thousands of lives are lost to overdoses every year. The need for action has never been more acute. And one of the most critical fronts in this struggle is, without a doubt, education and training. And that's where Harvard Medical School and our Harvard community can play a major role. Throughout history, we have repeatedly transformed how clinical practice and teaching are conducted. And as we work to save lives and alleviate suffering, it is our duty to do our part in addressing this issue. So we are especially honored to be joined today by a member of the greater Harvard family, as a graduate, someone who has been at the forefront of efforts to stem the tide of opiate addiction across the country. And that's Massachusetts Governor Charlie Baker. Governor Baker's commitment to reducing the burden of opioid addiction and to getting individuals, families, and communities affected by this crisis the help they need has been a centerpiece of his administration. Under his leadership, Massachusetts laws aim to address every facet of opioid addiction, from prevention to education, treatment, and recovery. Our state now serves as a model for the rest of the nation on how to create effective and actionable policies, particularly in medical education. We are making inroads in the fight against opioid addiction. Now, as one of the five members of the President's Commission on Combating Drug Addiction and the Opioid Crisis, Governor Baker continues to demonstrate his dedication to ensuring that the insights and lessons that make Massachusetts a national leader in addressing the opioid crisis will be able to help all Americans. We are proud to have Governor Baker here today. And we are equally honored to be joined by a fellow member of the President's Commission, Bertha Madras. Bertha has been a valued member of our Harvard Medical School faculty-- I hesitate to say this-- for more than three decades. Professor Madras is a former Deputy Director for Demand Reduction in the White House Office of National Drug Control Policy and has dedicated much of her accomplished career to treating and preventing addiction. With Governor Baker and fellow commissioners, she is currently engaged in a Herculean effort to articulate what needs to be done to address the opioid crisis on a national scale. I want to welcome the members of the Harvard Medical School community who are in the audience here today and the thousands watching this discussion online via live streaming. Your engagement and attention to this issue is crucial. It's incumbent upon all of us members of the medical community to be willing and able to not only treat opioid use disorders, but also to provide the current generation of clinicians and all future generations with the most advanced evidence-based opioid and pain management training, so that they, in turn, can provide their patients and community with the safest and highest quality of care. At HMS, we hope that our efforts to advance opioid education will create a body of best practices and teaching strategies that will serve as a resource for the world for public and professional audiences alike. And among our many efforts is a sweeping initiative led by HMS Dean for External Education, David Roberts, to develop online learning platforms that make vital opioid education materials accessible to public audiences around the world, as well as to serve the medical professionals through this continuing medical education program and to provide to business and industry leaders this same vital information. So here at Harvard Medical School, we are working to transform how tomorrow's doctors are educated about opioids and pain management. Many of these efforts have been spearheaded by Todd Griswold, the HMS Director of Medical Student Education in Psychiatry. And you will learn, as well, from him shortly. So we have a very, very impressive group gathered here today to address this critical issue. And I am thrilled, as I imagine all of you are, to hear Governor Baker, Professor Madras, and Dr. Griswold, Dr. Roberts. All of these panelists will be sharing their thoughts, their expertise, and their vision as we take a hard look at what we can and must do to end this deadly scourge. You will all have an opportunity to pose questions. I ask you to please write your questions on the index cards, hand them to one of our staff so that they can be addressed to the panelists. But now, let's get started. And please join me in welcoming our first speaker, the Governor of the great commonwealth of Massachusetts, Charlie Baker. [INAUDIBLE] [APPLAUSE] Thank you, Dean. And thank you very much for having this conversation today. You know, when I ran for governor, I didn't run to work on the opioid epidemic. It was one of those things that found me when I was a candidate. And it found me at first in the most subtle and sort of quiet way, which is, I would go out and I would do a town hall or a forum, or I'd speak at a VFW hall, or some other public gathering place. And at the end of my remarks, there'd be a Q&A. And then after the Q&A, people would just sort of mill around and ask me a question or two, or if they actually thought I might win, take a picture. That didn't happen very often. And then there was always a few people who were just kind of standing off to the side, literally, just kind of like this. I mean, I was over there somewhere. And they were just kind of not really part of the klatch, but just in the area. And then once everybody else left and cleared out, they would come up to me and they would say, you're a health care guy, right? And I'd say, well, I guess that depends upon how you define one. I mean, yeah, I've worked in health care a lot. And they'd say, I've got this friend. And they'd tell me their story about their friend. And it was always about addiction, and almost always about opioids. And literally, this happened everywhere I went, no matter what part of the commonwealth I was in, what neighborhood I was in, what kind of location it was. And it got to the point where I just started wrapping that up into my larger conversation about health care generally, hoping that I would give people in the audience permission to actually raise their hand and ask a question about it during the discussion. And that never really happened. It was still everybody gathers afterwards, and then eventually somebody would come up, or some group of somebodies. And now, it wasn't about a friend anymore. They were talking about their mother, their father, their brother, their sister, their son, their daughter. And they would tell me their story. And inevitably, at some point, they would say, it's been hell. Always hell. By whoever I talked to, that was kind of their bottom-line definition for what they were describing. And I literally went back to the campaign people after one of these and I said, look. This is all anecdotal. It's just what I'm hearing when I'm out there. And maybe I'm listening for it, but it sure sounds to me like there's something really big going on out there with this addiction issue. And I want you guys to look into it. And so they did what 20-somethings do, with no budget for research and somebody who wants the information tomorrow. They just got on their laptops and went nuts on it. And they came back, and they basically said they found some really interesting, terrifying statistics. One was, the US represents 5% of the world's population, but it was consuming 80% of the world's opioids. Then in 2014, we were on our way to writing 240 million opioid prescriptions, that 66% of everybody who gets admitted to a hospital usually leaves with an opioid prescription. 18% of those are still on it a year later. And 8% of those have a serious addiction problem. Now, if you started doing the math on that, the numbers get pretty big pretty fast. And at that point, I thought, OK. Some Saturday morning, I'm going to go visit some of the folks I know who worked in the ERs and just talk to them about it, and see what they have to say. And so I did that. And I went to two hospitals where I knew the folks there pretty well, and just grabbed a cup of coffee early in the morning on a Saturday with the folks in the ER. And I said, look, I'm hearing about this everywhere I go. I've seen some of the statistics. They're a little frightening. What's going on? Because usually the ERs are sort of the front door to a lot of stuff. And both of them said, yeah. It's a-- use your favorite word-- calamity, avalanche, disaster. And I literally took notes and listened to what they said. And I sort of stopped them at one point. I said, you guys have known me for a long time, like, 20 years. You knew I was running for governor. How come I had to come see you to find out about this? Because you clearly seem to think it's a problem. And they said, well, you know, there's only so much you can do. And we're just trying to stay ahead of it. And so then I went and visited with some folks in the first responder community. And by the time I was 3/4 of the way through the campaign, I was absolutely convinced that this thing was sort of a very big fire burning that wasn't necessarily getting the time or the attention of the focus that it deserved. And so one of the things we did, I talked about this shortly after the election, said I wanted to put together a working group to work on it. We did that. Terrific group of folks who did a series of public hearings around the commonwealth, and issued a report pretty quickly-- it was sort of 90 days plus or minus, beginning to end-- with about 60 recommendations in it, about half of which required legislation, and about half of which you could chase administratively. But one of the recommendations in there, under prevention and education, was requiring graduates of dental schools, nursing schools, pharmacy schools, and medical schools to take and pass a course in opioid therapy and pain management as a core part of their curriculum. And this came about because the conversation became pretty clear to them during their hearings that there are a lot of people out there prescribing who had never really taken a course in this and were sort of working off of something other than best practice with respect to the way they were making decisions. And the whole proposal itself, I would argue we're chasing virtually every element of that 60-page report. And you can find it on the internet, if you Google it. But it really had four big elements. One was this prevention and education piece, which was partly about practitioners, partly about teachers, and education, and coaches, and parents in schools. And part of it was about just raising the level of dialogue. We've done a whole series of stigma campaigns around Massachusetts. We'll continue to do that. Because it's very clear to us that, especially in this addiction space, it's much tougher for people to talk publicly about it and to talk about the nature of the illness and the disease than it is to talk about the nature and the illness of other diseases. There was an intervention piece, which was about doing a better job of providing practitioners with tools when they are writing prescriptions to get a sense about where they fit relative to their peers, with respect to the way they prescribe and how they prescribe, and better job collecting and providing data to people just generally around the practice, and the way people write and what they write for. And the new prescription monitoring program we put in place gets about twice as many hits per month as the old one does. It actually provides people with pretty decent reports with respect to what's actually going on and how they relate to many of their peers. And I do think it's had a positive impact on the way people prescribe generally. We also proposed a limit on first prescriptions for opioids on an outpatient basis of a three-day supply. Now, the legislature eventually settled on seven, which made it one of the first limits on first prescriptions in the US. And I'll come back to that one in a minute. We also put a significant amount of resources into treatment and recovery, and over the past couple of years have increased the commonwealth's investment in treatment and recovery by 50%, and have dramatically expanded the number of inpatient beds, the number of step-down beds, the number of day treatment programs across the commonwealth. And one of the things we did was we laid all the data associated with where overdoses were happening in the commonwealth on a map and then looked for places where we had mismatches between the amount of activity associated with overdoses and the available treatment capacity. And we learned that in some parts of Massachusetts, we had more than enough capacity. But in a lot of parts of Massachusetts, we had literally almost none. And so one of our objectives was to enhance our capacity on a regional basis and not just to think about it in terms of total statewide numbers. Now, that set of policy proposals became legislation. A big piece of it got passed. We've been implementing it. And what I would say about it so far is, we presented this to the National Governors Association after the legislation passed. And 46 other states basically signed on to various pieces of this platform. And if you read the New York Times editorial on this issue last Sunday, which was a full-page editorial, almost everything in that editorial that they recommend with respect to what we ought to be doing about the opioid epidemic, we're doing here in Massachusetts. And some of it we've been doing for a couple of years. So I do think in many ways we're heading in the right direction on a lot of this stuff. The data on trends with respect to prescriptions, overdoses, and deaths, which have gone up every single year for the past 15 years, nationally and in Massachusetts, for the first six months of this calendar year, starting in January, for the first time in 15 years, the year-over-year data on prescriptions and deaths went down. Now, I've had a bunch of people say, well, that could just be an aberration. My comment to that is, after 15 years of literally every single quarter, year over year, those numbers going up by 20% or 30% for 15 years, you have two quarters in a row where the numbers go in the opposite direction-- yeah, maybe that's an aberration. But our goal is to try and turn into a trend. And I do believe if you look at the work that's been done to expand treatment capacity, enhance prescribing education and public education generally, and distribute far more broadly Narcan, and to educate a lot of the folks who are in a position to take advantage of the distribution of Narcan, it shouldn't be that surprising that we've had some positive progress. The new wrinkle to this whole conversation is fentanyl. If you just took heroin and opioid overdose deaths, we've actually made a lot more progress there. The big problem we face right now is the fact that we now have a variety of synthetic opioids coming into this conversation that are a lot more dangerous and a lot scarier than what was there before. Fentanyl is one. Carfentanil, which has showed up in New Hampshire, is another. And one of the things we're hoping we can get our colleagues in the legislature to do is to have Massachusetts adopt the federal drug registry, so we can then make decisions as these synthetics become available to put them on our registry here in Massachusetts. We had to pass legislation to make fentanyl illegal to distribute and to sell. And if carfentanil shows up here, we're going to have to do the same thing with respect to carfentanil. I would rather literally be able to solve that problem administratively than have to deal with it that way. The two other things I just want to speak to briefly-- one is the seven-day limitation on first prescriptions. When we first proposed that, the medical community came at us pretty hard, really hard, and basically said, in effect, what are you doing, stepping on the skill sets and the capabilities of the medical profession and the dental profession to make the right decision on behalf of the people that they serve? This was after I'd already heard what percentage of people who graduated from dental school, medical school, pharmacy school, and nursing school had actually ever taken and passed a course in opioid therapy and pain management, which is less than 10%. But that's kind of beside the point. So I went to a meeting, literally the day after-- it was a breakfast meeting the day after we made that original proposal. And there was about 400 people in the room, almost all of whom were docs and nurses. And I made my pitch, made my presentation, explained why we were making this proposal, and then kind of stood back and waited for the response. And a hand went up. I called on the gentleman that raised his hand. And he said, I'm an ER doc. I came here straight from getting off my night shift. I brought three people back to life during my shift last night. It happens all the time. I think what you're doing is a good thing. And that just took all the air out of the conversation, with respect to whether we needed to start thinking differently about the way we were handling and dealing with prescription pain meds, and opioids in particular. The other thing I want to talk briefly about was, we had a commission meeting about a week ago in Washington. And we talked to some very interesting people, one of whom happened to be a gentleman working in the pharma industry in the US. But his background was as a surgeon in the UK. So, seeing a surgeon from the UK, part of the world where they spend 5% of the-- where they represent a much smaller piece of the opioid issue relative to their size, I said, so, we procure and distribute 80% of the world's opioids with 5% of the world's population. What do you do? And he said, well, he said, we would never write anybody more than a seven-day supply. That was point number one. We're trying to get to a seven-day supply as a minimum standard. He said they would never go over seven on a max. The second thing he said was, unless somebody is in really tough shape-- hit by a car, you know, fell out of a window, heavy trauma-- he said they would pursue a whole variety of alternative strategies other than using opioids to deal with that person's particular situation. And the other thing he said was, there's not a lot of evidence that on an outpatient basis, over a long period of time, it's a particularly effective way to manage chronic pain. And there were a few nods around the room when he said that, which just brings me back to this notion that one way an organization like this can play a major role in how we deal with all this is not just educating the current generation of prescribers and the next generation of prescribers, but it's also helping people think hard about the practical and clinical value of certain types of therapies, and helping people deal with pain, especially chronic pain. The legislation that we filed has exemptions for people who are dealing with chronic pain. This was about what I would call short-term, acute-type stuff. I still run into situations all the time where people come up to me and say, my kid had his wisdom teeth out. He came home with 20 Percocets. My daughter had gum surgery. She came home with 40 OxyContin. I mean, I'm sorry, people. There's just no justification to give anybody that kind of level of medication under those circumstances. And I think one of the things we all need to understand is that there are positives and negatives to this stuff. And we all need to be factoring those into the way we make decisions. You know, my son Charlie, in his last college football game, suffered a terrible injury. And this is, by the way, before I was running for governor, before I was running into these people, before I knew anything about it. And I'm somebody who spent a lot of time in health care. My wife and I have tried to think back on that and figure out how many pain pills that kid took. We don't know. But we think it's somewhere between 500 and 1,000 over the course of five or six months. And by some grace of God moment, it didn't stick with him. But not once, ever, in all of the conversations we had with the surgeon who took care of his original injury or the people who took care of him and treated him with respect to his rehab, did anyone ever say to him or to us, there's a downside to this stuff that you need to know about. Not once. And I can't tell you how important I think it is for the medical community in particular to articulate the positives and negatives associated with this, so people are aware of them and realize it. And the final thing I just want to mention, there's a book called Dreamland, which is written by a Los Angeles Times reporter named Sam Quinones. And it's the best thing I've read on how we got here. And one of the points he makes in this book, I think with remarkable clarity, is the non-addictive pain medication issue is a little bit like the chase for the holy grail. People have been looking for it for a couple of hundred years. And this country, in the first part of the 20th century, after they outlawed heroin and dramatically reduced the amount of utility and use of morphine-- mostly because of the consequences that came out of the Civil War-- spent a lot of money in dollar terms then, dollar terms now, trying to find this magic, non-addictive pain medication. And based on the thinnest evidence you could possibly imagine, people started to believe that this was, in fact, the solution to the problem of non-addictive pain medication, and for whatever reason, just missed some of the telltale signs that were everywhere with respect to what was going on. And I think it's really incumbent on everybody to recognize and appreciate that, while in certain circumstances this stuff makes a lot of sense, there are many circumstances in which it probably doesn't. And at a minimum, the people who are involved need to be making more informed decisions than they make now. Now, we're going to continue to invest in our prevention and education programs. We're going to continue to invest in our intervention programs. And we're going to continue to expand our footprint in treatment and recovery. Because those are the places where we think we can help. But it's going to be especially important for folks in the pharmaceutical, dental, medical, and nursing communities to sort of grab the ball and run with it, with respect to ensuring that we use this stuff in the most efficacious and safest way possible. And I really appreciate the fact that you're having this conversation. And God bless. Thank you. [APPLAUSE] Governor, thank you very, very much. Thank you for being such a brilliant student on this issue and for your leadership, which is literally translating into lives saved. Thank you so much. It's now a privilege to introduce Dr. Madras. [APPLAUSE] Thank you, Governor. And thank you, everyone, for coming here. The President's Commission on Combating Drug Addiction and the Opioid Crisis will have its final report issued November the 1st, which is in about a month from now. And we're all looking forward to this final copy, which I'm working on judiciously at the present time. These are my disclosures. I just want to highlight that very few of them have any financial issues related to them. The ancient Greeks had a term called pharmakon. Pharmakon meant a medicine and a poison. And there is no better illustration, no more dramatic illustration of this point, than the opioids. For they can both alleviate pain very dramatically in the acute phase, but they also can produce pleasure, the kind of pleasure that leads to people seeking them for addiction and also for overdose. Pain is the number one self-reported medical reason for using drugs with abuse potential. Because the pain and pleasure centers of the brain are closely linked. Let's take a look at some of the three topics that I'd like to cover today-- the national trends, the root causes, and some of the solutions. As Governor Baker so eloquently highlighted, the US leads in the world in prescription opioids. It is number one in terms of doses per million people. And the average is about five times higher than 30 of the most highly prescribing countries in the world. Pain is number one. The US also leads the world in opioid overdose deaths. It is an outlier with regard to the rest of the world. And what we're seeing in terms of trends up till 2016 is that all drug overdoses are up to 64,000 from 52,000. Prescription opioids are declining in terms of deaths. Heroin is still increasing. But right now, the scene has shifted, as Governor Baker so eloquently said. It is shifting towards fentanyl. And that requires, in addition to being concerned about prescription opioids, we have to be concerned about the use and supply of fentanyl. It has reached such crisis proportions in our country that first responders such as police are now being trained throughout the country to resuscitate people who've overdosed. There were 590,000 drug overdose deaths in the past 15 years, a three-fold increase in opioid use disorder. The death toll for 2016, unconfirmed yet by the CDC, is going to be about 64,000. The driving force of this epidemic was prescription opioids. That is something the medical community cannot deny. And what we are aware of is that approximately 80% of current heroin/fentanyl users transitioned from opioids. What are the root causes that are relevant to medical education? The root causes are inadequate medical education in generational forgetting. And I would like to just read, very quickly, a paragraph. Critics of the profession charge that a major source of continued abuse of opioids is inadequate medical education. Not only is the graduate of a typical school ill-informed about the danger of repeated administration of opioids, but his general lack of diagnosis skills tempts him to back on blind symptomatic treatment with opioids. When was that written? 1875. What has changed in over 150 years? Generational forgetting, because we had a prescription opioid epidemic in this country starting in the 1840s that lasted 1910 until the federal government intervened. Quality science. And I'll give you an example of that in a moment. Pain management and opioid prescribing is inadequate. And inadequate, also, is addiction screening and management. And more on that in a moment. What has happened now? We're seeing a change in the environment. In 2006, the first trip I took while serving in the federal government was to the American Medical Association headquarters. And I spoke to Dr. Mike Maves, who was the Executive Director. And I said, Mike-- we were on first-name basis after five minutes-- I said, Mike, we have to teach medical students about addictions. And he said, well, we're teaching them about alcohol and smoking. And I said, that's not good enough. He said, well, but the entire addiction field is disconnected from medicine. And I said, what about prescription opioids? And he slammed his hand on the desk and he said, now, you're beginning to make sense to me. And we became very forceful partners in developing SBIRT and getting CPT codes and H codes and G codes for it. But what traditionally happened in this country was a giant disconnect between rehabilitation centers and the health care system. And this giant disconnect had an enormous influence on the fact that medical schools began to ignore this problem. Generational forgetting and poor quality science is best illustrated in the following example. For decades, prescription opioids were avoided for chronic pain because there was generational remembering-- the remembrance of the first iatrogenic disease of opioid addiction. The concerns were addiction, overdose, and ineffectiveness. And then came a letter to the editor of the New England Journal of Medicine. Addiction is rare in patients treated with narcotics. We examined the incidence in hospitalized patients. There was at least one narcotics prescription for about 12,000. And we conclude that despite widespread use, the development of addiction is rare in medical patients with no history. Now, what happened as a result? The citations for this letter reached 600. The average citations for a letter to the editor is 10. 60-fold more people were citing this in an affirmative way, until finally, approximately 2013, there were some negative comments that began to predominate. And only this year are the negative comments the dominant ones. Up until then, there was affirmation that addiction is rare. So, the low-quality science received affirmation for decades. In 1980, when this was published, I was a practicing scientist. I could have read that little four-page article in five minutes and said, it's bunk. Why? How many doses were consumed by the patient? How long were they on opioids? Is it safe for chronic conditions? What about outside the hospital stay? Is it safe? How is addiction assessed? What were the criteria? What were the long-term outcomes? Any person trained in rigorous science would have asked those questions immediately. So the evidence of safety and effectiveness was weak, and the training was very weak amongst those 600 citations that said, this is good. This is really interesting. So the pressure for pain management with opioids mounted. They shifted the blame to the provider. There was articles about the tragedy of needless pain, a shift to pain as the fifth vital sign, with pharmaceutical companies sponsoring training sessions and professional medical societies, pain patients pushing and pushing and pushing for this mindset. The Veterans Administration adopted pain as a fifth vital sign. And the Joint Commission and other organizations for accreditation of hospitals and clinical providers began to pressure for accreditation for reimbursement. You have to satisfy a patient's pain needs. And so what happened? There was pressure on physicians for addressing pain with opioids. And every doctor's office and hospital room had a pain assessment tool. The focus was on pain management for prescription opioids. And prescription opioids increased dramatically over the past 15 years, and are just beginning to decline. And we became a nation awash in prescription opioids, awash with them. What is the current NSDUH data? 11.8 million people misuse prescription opioids. 2.1 have a prescription opioid use disorder. 626,000, heroin use disorder. And all of these are underestimates. And there's very ample reason for claiming that these are grossly underestimated. So, what are the pathways to an opioid use disorder for people who are prescribed these drugs? Inadequate pain control. Dose escalation without consulting a physician, a small percentage. Likability on initial exposure. And, initial use for psychoactivity, which means diversion of excess supply. That's the lion's share. Relief from emotional distress. That's an important one, because opioids can promote emotional serenity, sleep, and relaxation. And, pain and prior substance use disorder is another critical one. Why is that critical? It's critical because if you don't know a patient's history on addictions, you have no idea what is going to happen when they're reexposed to a drug that they may have been addicted to. In other words, the heroin will cue the brain initially when they progress to addiction. And then, if they have been treated and then re-cued with an opioid, they begin the slide to relapse. So, what happened? At the same time that prescription opioids were flooding our nation, heroin re-emerged with increased purity, with diminished price. And fentanyl, which was developed by Paul Janssen, was a derivative of meperidine or Demerol. That has re-emerged without anyone predicting the ravages that this would wreak on our society currently. And we had a perfect storm. The convergence of excess prescription opioids cuing people to like them combined with much cheaper heroin, more pure heroin, and much more potent fentanyl. And, as I said, 80% of current heroin and fentanyl users initiated with prescription opioids. What are the solutions? The solutions are many. The Surgeon General's Report tried to address them. The National Academy has tried. I think Governor Baker's rational approach has been exemplary for the rest of the country. It's an extraordinarily good approach. The president appointed a commission with three governors, former Congressman Patrick Kennedy, and myself to serve on it. And Pam Bondi was recently appointed. She's the Attorney General of Florida. And she issued some very important recommendations, including for pregnant women and families. Fortuitously, a day before I was asked to come to Washington to possibly serve on this commission, I had published in JAMA Psychiatry the responsibility and response of the medical community. The response is to screen at-risk patients. Why? Because Dr. Turner recently, in a Congressional testimony, testified that he had a patient who had seen over a hundred physicians. He had an opioid use disorder. Not one had asked him a question about addiction. Not one. When I served in government in 2007, there was an overdose death in West Virginia. When the DEA went to the house to try to clarify the origin of this overdose death, they found 100 prescriptions for opioids in possession of a single patient. So the prescription drug monitoring program that started in the early 2000s, we began to pressure every state to engage in this. Screening, intervening, and mental health analysis and integration of physical addiction and mental health combined is essential in order to address the issue on an individual basis. Reduce unnecessary opioid prescriptions. We now have billing codes. We have billing codes that were catalyzed in 2006 for private insurers, third-party insurers, for Medicaid, H codes and G codes, that enable a physician to set aside the time to screen. But the uptake on these-- we put it into the federal budget $235 million for the first year, so that the Medicaid would reimburse for them. And they were used at a rate of about 5%. Even though we had done an analysis of how to force change, which is financial incentives, nobody took up. We had three medical education conferences. We invited every dean of 125 or so medical schools and schools of osteopathy. Not one dean came to our conference. There was no interest at the time. Reduce unnecessary opioid prescriptions. We're all familiar with the CDC guidelines. But there's a lot of problem and pushback with them. And there are solutions. And one of the solutions resides, I think, with a member of the faculty of Harvard Medical School. Help patients who have a substance use disorder. If we do not diagnose the substance use disorder in patients who have an opioid use disorder, how are we going to address it? Yet in spite of this vast array of data, of press releases, of TV programs, of people crying for help and designations of epidemic and crisis, clinicians continue to prescribe opioids to 90% of the patients who've overdosed. And 63% of those who've overdosed get high doses, which means 60 MMEs, 60 milligram morphine equivalents, and above. And many of them overdose more than once. So the interim report on the President's Commission focused on medical education and opioid supply reduction. Those of you who feel queasy about using the word supply reduction and think it's a criminal justice issue, think about it as a form of prevention. It is a form of prevention. Prescriber education. The PDMPs. Reduce the barriers to critical information. Why isn't every hospital in the country reporting back to a primary care physician that their patients have overdosed? Why is that not mandatory? Treatment-- expanding treatment capacity, incentivizing medications, assisted treatment, and rescue. And of course, supply reduction. These are the primary points. Medical education is essential across a wide swath of clinicians and people who have a DEA registration to prescribe. The contents have to be both addiction and pain management. We are looking very judiciously at data analytics, big data analytics that can help in terms of addressing the problem. And as in 1910 when the federal government inserted itself with regulations, I fear that the regulatory oversight will just increase and increase if we don't put an end to it. We must also remember the patient. We must remember the consequences of stigma to the individual. And we must remember patient education. The red flags-- how many patients are aware that any one of these drugs can lead to a profound addiction, overdose, and death? Very few patients are aware of this simple fact. And so I just close with a very simple four-line poem by the father of Oliver Wendell Holmes. Alas, for those who never sing, but die with all the music in them. Weep for the voiceless who have known the cross without the crown of glory-- the people who have died prematurely because of this. Thank you. [APPLAUSE] Wow. Thank you very, very much, Bertha. Now, we will hear about educating tomorrow's doctors from Todd Griswold. Please. Well, thank you to Governor Baker and to Dean Daley and Dr. Madras. I'm Todd Griswold. I'm a psychiatrist at Cambridge Health Alliance. And at Harvard Medical School, I guide the psychiatry curriculum across the four years. So it's in that role, it's from that perspective as an educator, that I'll be speaking with you today about how we're responding to the opioid crisis at HMS through medical student education. So, medical schools have a solemn educational responsibility here. This is a quote from the draft interim report. This crisis began in our nation's health care system. And we have a solemn responsibility. Because we're facing a terrible public health crisis. And because physician prescribing has contributed to this crisis. But also because most medical schools, including HMS, have not done enough to educate our students about substance use and pain. So the role of education here is really vital. I'm sorry. Education can save lives. It can help change the course of this crisis. But we also recognize-- [INAUDIBLE] OK. I'm supposed to be miked here. But, OK. I'll stay here. Thank you. So, the role of education is vital. Education can change lives. It can help change the course of this crisis. But we also recognize that it's only part-- it's an important part-- but it's only part of an approach that we need for this complex problem. So how should medical schools be educating students to address this crisis? Well, first, we have to make education about substance use and pain a priority, a priority that would be equal to their importance in clinical work and in public health. And second, we need to make sure that students have the specific skills that they need to take care of patients who have addictions, who are in pain. And there's some very specific skills that Dr. Madras outlined that we need to teach students, about how to screen for substance use disorders, how to assess pain, how to treat substance use disorders and mental health conditions. But beyond the knowledge and skills, we need students to understand the human dimension. The backdrop here is from an article in STAT News, which had obituaries for many people who had died of opioid overdose. And we need students to understand the tremendous suffering and loss, but also the inspiration and the resilience of people when they're doing well, when they're in recovery. And lastly, prevention. Prevention is key. And we need students to understand how prevention works and the role that they can play in prevention. So, facing this at HMS, we made it a priority. We developed a comprehensive substance use and pain curriculum, which was a broad effort. It involved clinicians from all different specialties, all different sites. And the medical students really played a crucial role, in their advocacy, in their good ideas, and their hard work. And it was quite inspiring to see everybody come together about this. Clinicians, educators, students, everybody recognized, this is really important. We have to support this. We want to support it. Excuse me. Let me just adjust this here. It's important that rather than creating an addiction medicine course or a pain management course that would stand alone, we integrated this curriculum across all four years, in every course that was relevant, in every rotation. And the reason for this is really crucial. It's because substance use and pain are fundamental parts of all clinical medicine. They should not be considered just specialty areas that someone else takes care of, that you refer someone else to. This is an integral part of general clinical medicine. We need the students to experience that in their education. So, the classroom teaching is important. But if we don't reinforce and strengthen that teaching when they get into clinical care of patients, then we will have failed our students. And we will have failed our patients. So the curriculum development that we did, a very important part of it is identifying curriculum topics for the rotations. So when the students are working with patients, they're learning about substance use and pain as it's relevant to the setting that they're in. So whether it's primary care medicine, surgery, psychiatry, pediatrics, OB/GYN, neurology, radiology, we have identified curriculum topics in all these areas that should be central to the curriculum. We've posted them on the website for today's event so you'd be able to access them there. Sorry. Having a little trouble accessing this screen here. The other important aspect of the education in terms of patient care is students need to be directly involved in substance use disorder treatment, not just referring people to get treatment elsewhere. They really have to be experiencing this, seeing patients get treatment, and with that-- this is a book from SAMHSA on recovery-- with that, see patients in recovery. It's really important that students don't just see patients when they're in the midst of their worst struggles with addiction, but that they see people when they're doing well and they're doing better. It's also important that they see people with chronic pain who have regained a lot of function because of effective treatment approaches. So prevention is a key part of the curriculum as well. Naloxone, which is Narcan, is the overdose rescue medication. So all our students are trained in naloxone rescue through their basic life support training. Students are learning in multiple settings, safe prescribing of opioids, safe and effective, and also non-opioid approaches to pain. And this is a work in progress. But we have a goal that every student, by the time they graduate, will be fully trained in medication treatment of opioid use disorder, buprenorphine training. And this will make a difference, if this is established across medical schools, in terms of meeting the public health need of there being enough physicians out there who are trained and who are motivated to provide this lifesaving treatment. So we all need good educational information. Students, faculty, clinicians, we all need access to this. So we're beginning this process of trying to compile and collect some really high quality online educational information. We've started this process. Also, on the website for today's event, you'll see a collection of information from these sources. We used some of this information to inform our curriculum. There's a lot to be learned here. And our hope is that this will help inform medical student curricula across the country and will help affect practice and patient care. So, we're educating tomorrow's doctors. Today's students are tomorrow's doctors. And we have now a curriculum. We made it a priority. It extends from when they first put on their white coats on the left, right at the start, to the end when they graduate. And I have to say, the students today are inspiring. I mean, I really feel that most of them recognize the importance of substance use and pain in medical education. And we know-- I'm confident-- that our students are going to make a difference, whatever they go on to in the future, whether it's patient care, or research, public service, policy, advocacy. And importantly, I'm confident that our students have the principals and the initiative to teach up when necessary. So by teaching up, we mean that the students will actually help the residents and the attending physicians learn what all doctors need to know about this opioid crisis. So, this is the curriculum that we made a priority of. We've made a lot of important improvements. But it is still a work in progress. There's more work to be done. Part of the educational philosophy at HMS is continuous improvement. So we're going to be continuing to work on this. We're going to carry it even further. And we hope that it will stand as a model curriculum on substance use and pain. Because that's really our solemn responsibility. Thank you. [APPLAUSE] Wonderful. Thank you. Let's turn to Dean David Roberts to tell us about leveraging online learning for professional and public opioid education. David. Thank you, Dean Daley. Thank you, Governor Baker. Thank you, Professor Madras. And I have the honor of being with you today to build on what you just heard from Dr. Griswold. For those of you who don't know me, my name is Dr. David Roberts. I am Dean for External Education. And I am a pulmonary and critical care physician by training. And I have seen the devastation of this illness with my own eyes, through many ICUs and through many patients' journeys that I have participated in their care. I also want to welcome not only everyone who is here and thank you for your attendance, but also the thousands of people who are joining us online today. All of the things that I'm going to share with you today are available. They are free. I will direct you to them. One of our goals was to build connections to the community far beyond the walls here at Harvard Medical School. We wanted to bring to truly new learners across the world some of our greatest faculty, some of the concepts that we've understood from what works best in education, whether that's in person or online. So the two things that we're going to focus on today are global and continuing education programs for physicians and our Harvard Health Publishing programs for the general public. And again, everything that I'm going to show you is free and should be available with literally a click on your computer. One of the things that we recognized is that there truly is no silver bullet for this. And it really requires all of the key stakeholders having access to adequate information. And so one of the things that we did when we created all of our courses-- and that's both for physicians and for the general public-- was that we had a coordinated approach from our faculty and to the teams that were building these programs. And I see several of our faculty here in the audience today. And we're very grateful for all the time and work that they have spent with our teams in building these. We also wanted to leverage the power of online learning, so that we could have global reach, not only for our direct community. But just as we have thousands of people joining us today online, we wanted to be able to reach people literally around the world. We also want to have content that we could reuse and repurpose for very specific opportunities, which I'll tell you about in a moment, where we're able to take this content and leverage it in specific opportunities. So, imagine that you are a physician watching this today or you are taking care of patients. And whether you are a primary care physician who happens to have patients with an opioid use disorder or you're an orthopedic surgeon prescribing medication for post-operative pain, everyone needs to understand how to-- as these three courses that we have-- understand addiction, to recognize the key signs and symptoms of this, to understand how to counsel patients and to treat patients with opioid use disorders. So everyone who is a physician, or a nurse, or another health care provider today, really needs to understand this. And with funding from the National Institutes for Drug Abuse, we were able to create some fantastic courses that really provide key information. I will tell you some very practical things. And first of all, this is not only free, as I mentioned, they are on our HMS Global Academy platform. So in addition to putting the links to these courses on our website, literally, you can get to all of them just by googling HMS Global Academy. These represent 24 hours of content. And I see many of our members from our GCE team here today. And I want to thank not only Senior Associate Dean Ajay Singh and his lead on this, Elizabeth Bennert, for all their hard work. The entire team has put together a fantastic course. And I'd like to show you what this looks like. This is a trailer that will take about a minute to play through here. Let me see if I can actually make that work. You know, I speak a lot about using technology in education. And it is truly amazing, the number of times I tell people, don't say, and now I'm going to show you the video. But, now, someone is going to show you the video. Please hit play. Here we go. [MUSIC PLAYING] Hi. I'm Sarah Wakeman, course director for "Understanding Addiction" of the Opioid Use Disorder Education Program. In this course, we will discuss the current epidemiology relating to opioid use disorder and examine the changing perception of substance use disorder. We will recognize that it is treatable like other chronic diseases, such as asthma or diabetes. We will also take a look at the neuroscience of addiction and compare and contrast physical dependence versus opioid use disorder. Finally, we will look at co-occurring psychiatric disorders, how we can reduce negative consequences and address stigma and bias around substance use disorders in medical practice and society. Welcome to "Understanding Addiction." [MUSIC PLAYING] Great. So I want to thank Dr. Wakeman for that. And that is just an example of the kind of content that you would see on our online learning platform. Now, it's clear, and just looking out in the audience today, and I'm sure many of the people who are online with us today recognize that we've all been touched by this true crisis in many different ways. And whether you are an individual who has a loved one who is suffering from this and you want more information or you're wondering how I can avoid becoming addicted to pain medication, we'd like to provide you with information for the general public, for everyone who has questions about this. We partnered with HarvardX. And this is a massive open online course, a so-called MOOC, that is free and available to everyone. It's called "The Opioid Crisis in America," or OpioidX. And again, I want to thank Dr. Greg Curfman and Cathy Finn from our Harvard Health Publishing team who are here today, and all of the faculty who worked with them and their staff to produce these fantastic modules. This graphic shows you many of the things that this course covers-- the history of this issue, how we should actually be managing pain, what are the challenges in terms of risk for addictions, and much, much more. And again, I'd like to show you just a very short clip of this to give you a sense of this. And I would encourage all of you-- the link to this course is directly on the website. I'd encourage you to go and click on it. Sign up for this. We've had over 10,000 people sign up for the course. And I think that speaks to the need and the interest for this kind of material. So again, I'm going to ask my colleague to hit Play here for this. Great. [MUSIC PLAYING] Well, I know addiction to pain killers is a huge issue all over the country. And many people are overdosing. I've heard that people are sometimes taking heroin when they can't get their prescriptions filled. I've heard that doctors prescribe too many pills and that's how you become addicted. The epidemic of opioid addiction has affected all geographic areas of our country, urban and rural, young and old, and people of all socioeconomic classes. No demographic group has been spared. And in this course, "The Opioid Crisis in America," we aim to teach you about the risks these drugs pose. Our major goals for this course-- to show you the silent nature of addiction, meaning how quickly someone can develop a problem and become addicted to opioids; to show you that addiction is a disease, not a lack of will or a character flaw. We will provide you with the latest information about effective treatments and tools to sustain recovery. My fellow colleagues in this course are researchers, health policy experts, and doctors who specialize in treating people with addiction. Together, we will provide you information about safer medical use of opioids, how you can avoid misuse and addiction, and the options for addiction recovery. I invite you to join us on this journey. [MUSIC PLAYING] I just want to thank my Publishing colleagues again for really producing a beautiful course. And I think one of the things that we've seen a lot is that there are professionals, health care professionals, who may not need continuing medical education credits as physicians or nurses, but as recovery coaches, or people who work in human resources as professionals, may need additional training. And that is something that we've seen quite a lot of. So what's coming next for us? One of our goals is to provide additional accreditation for professionals who need training from some of our online courses. We've also recently gotten additional funding from the National Institutes for Drug Abuse for a course on neonatal abstinence syndrome. We are taking this content and sharing this across the country and across the world. And we're actually doing a number of events where we are bringing our faculty to communities to talk about these issues. I will highlight that one of the other things that's on our website today, the Breaking the Cycle e-newsletter, is something that you can sign up for and receive, again, free. You can get regular updates from us about this topic area. For those of you who are interested or you have additional questions beyond what we can answer today, please do not hesitate to reach out to us. Our contact information is both on this slide and on the website. And we would love to hear from you. And if we can answer questions, if we can provide really useful information to you, please do not hesitate to reach out. Thank you again for your attendance, your interest, and I'll look forward to the questions. Thank you, Dean Daley. [APPLAUSE] I'd like to invite the speakers to come to the front to constitute our panel. If there are any in the audience who have questions, please ask you to write them on the index cards and they'll be passed to the front. We have about 15 minutes to receive and respond to questions. I'd like to start-- one of the questions that came in is, how will the opioid overdose reversing drug naloxone, Narcan, be made more accessible? Why can't it be available as an injectable pen over the counter in every pharmacy in the United States, with instructions for lay users? How might we respond to that? I'm not miked. Dr. Madras? Oh, let's-- do we have a mic-- There we go. --there for her? [INAUDIBLE] Thank you. I can only speak to what is being discussed currently at the opioid commission on the accessibility of naloxone for over-the-counter or by other means. There is an obvious benefit. Thousands of people's lives have been saved by having access to the drug. There is also a concern that we are going to have a lot of anonymous people overdosing, rescuing themselves, without ever having the opportunity to encounter the health care system and treatment providers. So from my perspective, it is very important to make it as widely available as possible, but with the caveat that so many people, the latest data we have, for example, from New Hampshire, is that the vast majority of people are dying alone. They're dying in their houses, unable to have anyone help them, and unknown to the health care system. And I think that's an issue that has to be looked at very carefully. One other point to note, that in our courses, we actually specifically address this from the education perspective. We show how these medications are used. We actually try to provide people with the core concepts, so that if the drug is available to someone, that they could actually know how to use it. And I think, just like Todd's programs that train students in this as part of their basic lifesaving, we wanted to try to put this information out there for both the general public and for physicians. OK. Perhaps for Todd, can you comment on the state of medical education in terms of addiction training nationwide? It sounds like you've taken a leadership role here locally. What's happening across the nation? Well, I'm not really an authority on addiction education across the country. So I wouldn't really want to make a sweeping statement about it. But I do feel that it's safe to say that addiction is an enormous public health problem, enormous clinical problem. It's everywhere in clinical medicine. And medical education has really never kind of right-sized addiction education. So I think that it is dramatically improving. I think that the opioid crisis has woken up-- maybe that's not the right metaphor-- but people have really become alarmed by this, rightly so. And so I think that it's improving. But I think there's a long way to go. Any other comments [INAUDIBLE] 10 years ago, I commissioned a company to survey all the medical schools in the country to find out what they were teaching with regard to addictions. And less than 30% of the medical schools had a systematic course on addictions, on pain management. That number has improved. But there hasn't been the kind of formal assessment that was done 10 years ago. Thank you. Are there any strategies to allow easier access for prescribers to become credentialed in Suboxone prescribing? Do you want to take that? [INAUDIBLE] Well, that's a federal regulation. And what is remarkable is that every physician who has a DEA registration can prescribe any scheduled compound except for the two agonists-- partial agonists-- methadone and buprenorphine, that have been FDA approved for treating addiction. So this is something I can assure you the commission is looking at. The problem is that many people who've taken the course feel that it's invaluable in terms of understanding addiction, per se, because they've never taken it in medical school. So this is a way of at least accumulating, in 8 hours of time, some strength in that area. But if it's mainstreamed through medical school, as Harvard Medical School is doing now, it's going to have an enormous impact in the future. The problem also is that of the number of people who've taken the course and have a waiver so that they can prescribe buprenorphine, only less than half-- much less than half-- actually exercise their ability to use their course and prescribe buprenorphine. So there is reluctance on the part of the people who even know how to do it to implement and to distribute and to prescribe. And there's also regulatory oversight, which may become moot if every medical school teaches it. So the reluctance to prescribe is one of the main reasons that we want our students to have experience with working with providers who are prescribing buprenorphine in their practices and seeing patients get better, seeing how it works, feel comfortable with that, and feel motivated to practice in that way. The other thing is that we are hoping that our addictions curriculum can count-- that the students can get credit for that as part of their buprenorphine training. So rather than having to do this full eight-hour thing for which they've already learned either all of it or the vast majority of it, they would learn a more buprenorphine-specific component sometime within their HMS curriculum. And then when they leave, they're ready to go. So there's administrative and regulatory issues that need to be sorted out about that. But that would be our hope, that that would be possible. Thank you. Continuing, a provocative question. By cracking down on prescription opioids without having a proper treatment infrastructure for addicts, aren't you pushing addicts to synthetic alternatives like fentanyl? Someone want to comment on that? It's all you. [LAUGHTER] We didn't say they would be easy questions. It's certainly not a laughing matter. It's a very difficult matter. There is a great deal of controversy on who has transitioned to heroin/fentanyl. There is evidence that some of the people who have been cut off from prescription opioids have transitioned to illicit sources of heroin and fentanyl. But the actual breakdown of the data is something that we don't really know. We don't know if many people who've been cut off from diverted prescription opioids represent the lion's share of the people who are now using heroin and fentanyl, or if it's bona fide pain patients, or a combination of both. I think for bona fide pain patients, it is essential that we create an infrastructure that's going to help them in the transition to alternatives, or tapering, or medications assistance for those who developed an addiction to their prescription opioids. I think there has to be a very humane approach, understanding that pain and addictions, both of them can cause tremendous personal and family anguish. And to simply say, no more, is not a wise policy. But, the other thing is, we have to understand how many people have become addicted to prescription opioids who were never prescribed them in the first place. And that's an important number that is not carved in stone yet. And whether or not we can identify those individuals and help them through with effective treatment as well. So, here's a question from a pain management specialist in training who says, I have two concerns. First, I'm concerned that a root cause of the opioid crisis is the presence of cultural, financial, and legal barriers to utilizing non-opioid medications-- nerve blocks, advanced palliative procedures, and other alternative methods. In other words, there is cultural, financial, and legal barriers that actually promote the excessive use of opioids. You might comment on that. And second, there are no chronic pain providers on the opioid crisis commission, even though they are one of the specialists most affected by this crisis. Do you have any comments or thoughts? So, a two-part question. Well, the person who asked that question, please email me. It's bertha_madras@hms.harvard.edu. Email me the barriers that you see for alternatives. Just delineate them. That's very important. And do it in a hurry. Because-- Well, alternative-- are there sort of problematic incentives for using opioids? Yes. Or-- And the second question was-- --prescribing-- And why are there no chronic pain providers on your commission? The commission currently is composed of and will end with three governors, a former Congressman, and myself, and Pam Bondi, an attorney general. One would say, well, where is the depth and expertise in medicine on the commission? One thing we have to recognize is that governors who have had to deal with it have consulted every expert in their states and across the nation with regard to implementing programs and policies for their state. If you can recognize that Governor Baker who was here just a few minutes ago, he never went and by [INAUDIBLE] decided how to address this program, the state program. He recruited some of the finest experts in the field, from the Mass General, from all over the state. And every one of those governors consults with physicians, with treatment centers. They synthesize, they extract all the feasible information. So I think one generally has the sense, well, they are politicians. But when a politician is dealing with a public health crisis or a public health issue, they have at their finger tips every expert they need and want in order to consult and develop effective policies. And what has enlightened me enormously by serving on the commission is the depth of their understanding of what can be done, what hasn't been done, and they may not know the exquisite literature on each of these issues, but they have access to the Secretary of Human Health and Services, the ex-secretary. They have access to NIDA. They have access to SAMHSA. They have access to every possible document. And many documents exist that are not visible to the public or to medical schools that summarize the cost-benefit equation of every single recommendation that is being looked at for the final report. And included in that are all the controversies with regard to pain management, all the literature. There's a team of people who are working judiciously. And I can give you multiple examples of the type of issues that are being dealt with as well as the cost-benefit equation, what some people on one side feel about an issue and contrary opinions, and recommendations based on looking at all sides of these issues. There is an enormous depth behind developing and generating recommendations for the future health and well-being of the country. Thank you. And I might add, from the educational perspective for the medical students, we made a clear decision to develop the substance use and pain curriculum together-- substance use and pain. The field of pain medicine is huge. The field of substance use disorders and medicine and psychiatry related to that are huge. There is some overlap. We wanted to develop these together because of the crucial relationship that they have in the opioid crisis, and also to try to guard against going a little bit too far in one direction or another, based on different priorities and this risk-benefit balance that we need to try to address. So, a factual question. Does the undertreatment of acute pain lead to the development of chronic pain? And alternatively, does the undertreatment of acute pain lead to the use of non-prescribed opioids that might be obtained illegally? So, the relationship between undertreatment of acute pain and the development of chronic pain and the use of illegal opioids. I'm going to learn from you. I think that's a data question. And I'm not comfortable in citing all the data. Because I don't think it's thorough and systematic at this point. So there's inadequate knowledge to be able to address those questions? There is not a full adequate knowledge. And this is a private conversation which will now be broadcast. But I had a conversation with Dr. Francis Collins, the head of NIH, just last week. And I said to him, what do we know about the types of pain complaints that give rise to the progression to addiction? Which people are most at risk in terms of their type of pain? And he said, I've never heard that question asked. And I don't know the answer. Let's talk to Nora Volkow-- who was standing there-- who's the head of the National Institute of Drug Abuse. And I asked her the same question. And she said, that's one of the data points we don't have. And so, I can't speak for what the final commission report will be. Because it will have to be a consensus voted by all the members. But one of the things that I'm advocating for is including a list of all the unknowns that we have in data, the gaps, that will help us in formulating future responses to the crisis. And then let me finish with one question. Most physicians, myself included, strongly support the measures discussed today. But how are doctors engaged as allies and not as adversaries? Well, I'd say, from the educational standpoint, we-- and maybe I'm not fully understanding the question-- but we've had nothing but an experience of allies in the sense that all the physicians, all the educators that we have interacted with, have supported this. Nobody has approached us with this attitude of, this curriculum, including this is somehow a burden or a mandate, or any kind of pushback or resentment. It's been very understood how important it is. I think that question is underpinned by the sense that physicians through their prescribing practices have played a role in establishing the substrate of this epidemic. And we have to be aggressively engaged in the solution to the problem. And I think what you've introduced us here today, the recognition of the problem, the efforts at education, and making available through readily accessible online sources the information we hope can go a long way to addressing these deep concerns. I want to thank the panelists for their commentary. I want to thank them for their passionate engagement in trying to address this terrible crisis. And we hope that in the future, we'll be able to make headway. And for that, we will be thankful to your efforts. And thank you all in the audience. We had over 3,500 listening in on live streaming. So this is obviously an area of enormous interest. And we certainly hope to see this as a change in an otherwise very worrisome trend. Thank you very, very much. [APPLAUSE]

See also

  • Opium production in Afghanistan
  • "World Drug Report, 2016" (PDF). United Nations Office on Drugs and Crime.
  • World Drug Report, Wikipedia

References

  1. ^ a b c d e f g h i j k l m "World Drug Report 2011" (PDF). United Nations Office on Drugs and Crime. 2011.
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az ba bb bc bd be bf bg bh bi bj bk bl bm bn bo bp bq br bs bt bu bv bw bx by bz ca cb cc cd ce cf cg ch ci cj ck cl cm cn co cp cq cr cs ct cu cv cw cx cy cz da db dc dd de df dg dh di dj dk dl "World Drug Report 2006". United Nations Office on Drugs and Crime. 2006.
  3. ^ "World Drug Report 2009" (PDF). United Nations Office on Drugs and Crime.
  4. ^ Cite error: The named reference world_2010 was invoked but never defined (see the help page).
  5. ^ "US heroin use has increased almost fivefold in a decade, study shows". Guardian Source: Columbia University Mailman school of public health. Retrieved 5 February 2018.
  6. ^ "Estimates of the Prevalence of Opiate Use and/or Crack Cocaine Use, 2011/12: Sweep 8 Summary Report" (PDF). NTA NHS Report. NHS. Retrieved 10 January 2017.
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