The use of prescription and/or unregulated opioids increases a person's risk of experiencing respiratory depression and fatal overdose.  Some people are at higher risk of experiencing respiratory depression due to the characteristics of the substance taken, underlying conditions, drug interactions or social and environmental factors.  This program will teach participants how to effectively recognize and respond to an opioid-induced breathing emergency using the antidote naloxone.  Principles of harm reduction will be discussed to help participants understand some of the barriers people who use unregulated substances face on a daily basis. 

Learning Objectives:

1.  Identify risk factors for opioid-induced respiratory depression.

2.  Explain the cycle of opioid use disorder and mechanism of the opioid antagonist naloxone.

3.  Describe the process of responding to an overdose including supportive care.

4.  Discuss myths and stigma related to responding to an opioid-induced breathing emergency.

An overview of NIDA’s current medications pipeline for the treatment of opioid use disorder (OUD) is presented. OUD and its consequences are a major public health concern with a devastating opioid use and overdose crisis in the US. Misuse and abuse of prescription opioids (including fentanyl), heroin and others are associated with a high burden of morbidity and mortality. It has been reported that around 50 million adults suffered from chronic pain in 2019. Opioids that are often prescribed for their treatment can lead to opioid misuse and OUD. Approximately 2.4 million Americans have OUD and many started their addiction with prescribed opioids. One of the most devastating consequences of opioid misuse is opioid overdose, which can produce respiratory depression and death. Drug overdose is the leading cause of accidental death in the US, with an estimation of 70,630 deaths in 2019; 49,860 of those being overdose deaths related to opioids. Medication-assisted treatment is a recommended treatment for individuals with OUD. Although there are safe and effective pharmacotherapies for opioid use disorders and to prevent/reverse overdose, their use has some limitation or they are largely underutilized. Methadone and buprenorphine are approved by the FDA to treat OUD but long term efficacy and treatment adherence are sub-optimal. As mu-opioid full and partial agonists, respectively, methadone and buprenorphine have abuse liability and there is well-documented misuse, abuse, and diversion of these products, particularly in high-risk populations such as those with OUD. Naltrexone, an opioid antagonist, is approved by the FDA to prevent opioid use relapse in people with no physical dependence to opioids but initiation and adherence to treatment are low. Naloxone, an opioid antagonist, is approved to reverse opioid overdose but it has a short action, may precipitate opioid withdrawal, and put the person at risk of overdose. And finally, Lofexidine, an alpha-2-adrenergic agonist, is approved for the treatment of opioid withdrawal in adults but it is not approved to treat pregnant women and neonatal opioid withdrawal syndrome. Other medications such as gabapentin, pregabalin, cannabinoids, ketamine, and ultra-low doses of oral naltrexone, as well as rapid opioid withdrawal under anesthesia, have been investigated, but the results are inconclusive. So despite the availability of multiple medications for OUD, the ongoing overdose crisis indicates the need for improved treatment options. To address this issue, in 2018, the National Institutes of Health (NIH) established a set of research priorities reflecting urgent unmet needs across areas of promising scientific opportunity, and concrete strategies capable of providing rapid and durable solutions to the opioid crisis known as Helping End Addiction Long Term or NIH HEAL Initiative. One of NIDA’s major role in the HEAL Initiative was to support studies to accelerate the discovery and development of novel medications to treat the opioid addiction cycle. This program is including the development of new formulations of existing medications, stronger and longer-duration formulations to counteract opioid overdose, interventions for respiratory depression, novel medications to treat withdrawal, craving, progression and relapse, and new medication targets to treat OUD and improve the quality of life of people recovering from OUD. These efforts are described in this overview and do not include other therapies such as devices, digital therapeutics or behavioral approaches. 

Learning Objectives:

1.    Explain current limitations of marketed FDA-approved therapies for the treatment of OUD.

2.    Identify drug candidates with novel mechanisms (not targeting the opioid receptor) currently in development for the treatment of OUD.

3.    Identify advantages of potential new formulations of already FDA-approved therapies.

Stimulants are the drivers of the fourth wave of the US drug overdose epidemic. Although most national attention and resources have been targeted at combating opioid use due to the surge of deaths related to fentanyl, recent reports suggest populations that use opioids are also using methamphetamine (MA) at high rates. Indeed, current data show that as many opioid overdose deaths involved psychostimulants as did not. These epidemiological data underscore the significance of developing efficacious treatments for methamphetamine use disorder (MUD) – especially in the setting of ongoing opioid use. Most therapeutic trials for MUD have failed with a few exceptions. Two randomized controlled trials (RCTs) showed that 30 mg of mirtazapine reduced MA use by 27% at week 36. A recent RCT completed by the clinical trials network (CTN) tested injectable naltrexone plus high-dose oral bupropion 450 mg/day compared to placebo and reported statistically significant reductions in methamphetamine use in a broad sample of people with MUD. This combination pharmacotherapy is impossible to use among those who use opioids as the opioid antagonist naltrexone precipitates immediate opioid withdrawal, further underscoring the need for a pharmacotherapy strategy without an opioid antagonist. As a monotherapy, buprenorphine (BUP) has sufficient rationale for evaluation as a medication for MUD in the setting of opioid co-use. Findings from another CTN study showed that extended-release Naltrexone plus oral BUP, produced modest, though statistically significant, reductions in cocaine use among those adherent to oral BUP. These findings provide initial support for a kappa antagonist approach to treating MUD, as the combination pharmacotherapy leaves only a kappa antagonist working at the opioid receptor. While there are no placebo-controlled RCTs of Bup for MUD, a recent clinical report showed patients treated for OUD using Bup showed a 15% reduction in MA use from baseline to follow-up.

Learning Objectives:

1. Demonstrate an understanding of the definition and epidemiology of stimulant use disorder, especially in the context of co-opioid use.

2. Describe the neurobiology in development and maintenance of stimulant use disorder and how this relates to treatment outcomes.

3. Review evidence for advancements in pharmacotherapies that can be brought into practice.

The collaboration between forensic toxicology laboratories and public health organizations can be a critical tool in guiding public safety and public health decisions to help address the significant public health crisis that has arisen from the increasing use of prescription and illicit opioids. This presentation will provide an overview on the role of forensic toxicology in providing analysis, interpretation of results and research on the different opioids that have been detected throughout the opioid epidemic. The different categories of opioids detected in each wave of the opioid crisis will be discussed including the challenges that result from the proliferation of newer synthetic opioids including fentanyl analogues, and other novel synthetic opioids such as U-47700.

Learning Objectives:

1. Define the opioid crisis.

2. Identify the different types of opioids that have been observed at different stages of the opioid crisis.

3. Explain how forensic toxicologists can collaborate with public health and law enforcement agencies in identifying and interpreting opioid concentrations in forensic casework.

The United States continues to struggle with a comprehensive, effective strategy to address alcohol and drug-related morbidity and mortality. Challenges resulting from the COVID-19 pandemic worsened the situation. In 2020, over 93,000 Americans died from a drug-related poisoning (i.e., overdose) the majority of which included an opioid, a 24.9% increase over the prior year. Methamphetamine-related overdose deaths have nearly tripled over the past 4 years. This occurred at a time when significant federal, state, and local resources are invested in reducing opioid and other drug-related morbidity and mortality. This represents one of the greatest public health failures in our generation. Unlike our current pandemic, there is a longstanding body of robust science and practice-based evidence to mitigate the so-called “opioid crisis”. However, these programs are not fully accessible and barriers to their implementation continue. Using a set of statewide initiatives in Texas, this presentation discusses the underlying rationale, approach, and current status of a suite of systematic interventions intended to increase access to compassionate, evidence-based treatment for opioid and other substance use disorders including medication, stigma reduction, peer recovery support services, and systems level interventions.

Learning objectives:

1. Define critical components of a comprehensive approach to statewide OUD treatment program.

2. Identify ongoing challenges with care delivery for OUD treatment.

3. Explain how technology and telehealth helps to overcome barriers to access to evidence-based treatment for OUD in underserved areas.

Most hospital systems have implemented opioid-related stewardship programs. That is an important first step. This talk will take that work to the next level, describing four advanced concepts in opioid stewardship. Attendees will learn cutting edge techniques for creation of metrics, dashboards and clinical decision tools, addressing post-operative opioid prescribing, implementing a high-dose opioid tapering program, and treating substance use disorder.

Learning Objectives:

1. Describe how creation of opioid guidelines can inform metrics dashboards and clinical decision support.

2. Discuss the scope of post-operative overprescribing of opioids and implement guidelines to address it.

3. Identify challenges and opportunities for implementing a high-dose opioid tapering program.

4. Describe an innovative model to address substance use disorder treatment at a hospital.

In recent years substance-related overdoses, many of which involve opioids, have contributed to more deaths than car accidents. Opioid Use Disorder (OUD) is a medical condition that continues to be highly stigmatized, which exacerbates these losses and increases barriers to improving the opioid crisis. Stigma comes in many forms (e.g., self-stigma, social stigma, and structural stigma). Each of these forms of stigma serve to increase discrimination and can be barriers to treatment seeking, resulting in continued use of substances and the devastating impacts of the opioid crisis. Stigma creates a vicious cycle that requires evidence-based and intentional efforts to combat. It is important to focus efforts on increasing education, increasing the use of recovery language, and building an understanding of evidence-based treatments. This presentation reviews the opioid epidemic, including base knowledge of what opioids are, use of non-stigmatizing language, and an evidence-based treatment overview. The importance of stigma reduction in the fight against the opioid crisis is discussed. 

Learning Objectives:

1.    Recognize and explain the potential dangers of opioids and the current opioid crisis in the United States.

2.    Recognize evidence-based treatments for Opioid Use Disorder.

3.    Develop effective methods for reducing self, social, and structural stigma.