1. Edward Lynam, MD
Medical Director
Quest Counseling, Reno, NV

2. Remembering History
 “Those who cannot remember the past are doomed to
repeat it.”
 George Santayana

4. Commercialization of Opiates 1
 British East India Company
 Tea from China
 Boston Tea Party!
 Silver to China
 Silver shortages
 Opium from Bengal/India to China
 Qing Dynasty
 Opium War(s)
 Silver and Tea from China, Opium to China

5. China
 By 1940: 40 million opium addicts, 10% of population
 A century of corruption, decline, and defeat
 Mao and Communists: solved addiction problem

6. Commercialization of Opiates 2
 Purdue Pharma, 1990’s
 Oxycontin: sustained release oxycodone
 Marketing drove it from $48 million in 1996 to $1
billion in 2001
 $200 million in marketing in 2001 alone
 Free 7 to 30 day supplies
 Bonuses to sales staff more than base salary
 5000 health professionals given all expense paid stays
at fancy resorts to become speakers

7. Medical Use of Oral Opiates
 Dysentery and Diarrhea (historical)
 Cough Suppression (rare)
 Pain Management
 Acute
 Pre-op
 Op
 Post-op
 Chronic
 Cancer, end of life: palliative
 Non-cancer

8. Effects of Opiates
 CNS and PNS opiate receptors (therapeutic):
 Decreased pain perception: analgesia
 Decreased reaction to pain: psychological
 Increased tolerance to pain: more functional activity
 Mild to severe neurocognitive impairment
 Nausea and/or Constipation
 Itching and miosis
 Immune/Reproductive hormone changes
 Accidents and delayed return to employment

9. Effects of Opiates in Addiction
 Above therapeutic dosage
 Euphoria: false sense of exaggerated well being
 Accelerated development of tolerance
 Respiratory depression leading to hypoxic death
 Cuts the normal response to carbon dioxide
 Lungs can fill with fluid
 Tolerance to this effect not predictable at high doses
 Half of deaths had used another respiratory depressant

14. Misuse of Prescription Opiates
30 to 40% of
prescribed doses are
not used properly

15. Engaging Prescribers
 Federal Efforts: starting 2011
 Office of National Drug Control Policy
(ONDCP)
 Food and Drug Administration (FDA)
 Drug Enforcement Administration
(DEA)

16. Strategy
 Expand awareness and education to physicians,
researchers, and the public
 Expand efforts to monitor the prescribing of these
drugs, including calling upon every state to set up
a program (43 so far)
 Make it easier for consumers to dispose of drugs
 Shut down “pill mills” and reduce doctor shopping

17. Educating Prescribers
 Training: substance abuse in general curriculum
 DEA licensure: requiring specific educational content
 Manufacturers: requiring “re”-educational funding
Opioid Risk Evaluation and Mitigation Strategy (REMS)
 Physicians for Responsible Opioid Prescribing (PROP)
 Best Practices for Emergency Medicine

18. Washington State
 Agency Medical Directors Group
 Published guidelines
 Opiate dosing calculator (web and app)
 Free patient assessment tools
 Free 4 hour CME activity
 Searchable Directory of Pain Management Specialists
 Other resources

19. What do prescribers need to do?
 Establish a clear upper limit on dosing
 Written care agreements
 No early refills or replacement of lost or stolen
 Refills only on clinic visits
 Random urine screening
 Red flags: end access
 State monitoring system
 Engage family in safety education

20. Conclusion
 Historically Opiate Addiction is linked to
commercialization
 Prescription Opiates have legitimate medical role
 A large percentage end up being misused or abused
 Unintentional deaths have skyrocketed
 Public education is important
 Prescribers need greater education
 States can help with monitoring, disposal programs,
shutting down pill mills, and doctor shopping