14th Annual Maryland Patient Safety Conference Medication-Assisted Treatment: A Priority Response to Maryland s Overdose Crisis

Transcription

1 14th Annual Maryland Patient Safety Conference Medication-Assisted Treatment: A Priority Response to Maryland s Overdose Crisis Kathleen Rebbert-Franklin, LCSW-C Behavioral Health Administration (BHA) April 13, 2018

2 Maryland Picture: Rise in Opioid-Related Emergency Department Visits 2

3 Maryland Picture: 2007 to

4 Maryland Picture: 2007 to 2017 YTD 4

5 Maryland Picture: 3 rd Quarter 2017 Opioid Related Deaths 5

6 Maryland Picture: 2007 to 2016 Total Number of Drug- and Alcohol-Related Intoxication Deaths by Selected Substances

7 Maryland Picture: 2015 to 2017 YTD Percent of Drug- and Alcohol-Related Intoxication Deaths by Selected Substances YTD 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% YTD 7

8 Maryland Picture: 2015 to 2017 YTD Number of Drug- and Alcohol-Related Intoxication Deaths by Selected Substances YTD YTD 8

9 Maryland s Response to Opioid Epidemic- State of Emergency March 1, 2017, Governor Larry Hogan signed Executive Order declaring a State of Emergency in response to the heroin, opioid, and fentanyl crisis This declaration: Activated the governor s emergency management authority, increasing rapid coordination between the state and local jurisdictions Allowed for $50 million in new funding to address the crisis Created National Incident Command Structure Created appointment of senior emergency management advisor Clay Stamp as lead 9

10 Four Statewide Goals for Opioid Epidemic Overarching goal is to reduce the rate of overdose deaths among Marylanders Goal 1: Prevent new cases of opioid misuse and addiction Goal 2: Improve early identification of and intervention with opioid addiction Goal 3: Expand access to services that support recovery and prevent death and disease progression Goal 4: Enhance data collection, sharing, and analysis to improve understanding of and response to the opioid epidemic 10

11 Goal 1: Prevent New Cases of Opioid Misuse and Addiction Priority 1.1 Reduce inappropriate or unnecessary opioid prescribing and dispensing among healthcare providers Key Strategy: Public Awareness Campaigns Talk to Your Doctor: Campaign to address lack of patient-doctor communication regarding the potential harm/risks of opioids PSAs drive viewer to website- Mother & son in Urgent Care (sports injury) Construction worker in Emergency Department Daughter with elderly parents discussing medications Website: Training video with prescriber/patient scenarios, Q&As, information on naloxone Roll out in targeted jurisdictions with high opioid prescribing rate, then statewide 11

12 Talk to Your Doctor (TTYD) Campaign Encourages patients to ask their medical professional questions if they are being prescribed an opioid yourdoctor/ TalktoYourDoctor.org Specific page for TTYD on the Before It s Too Late Site Contains list of questions to ask with potential answers Training video showing different patient/doctor scenarios 12

13 Talk to Your Doctor Geo-Fencing: creates a virtual geographic boundary around (an area) by means of GPS or Radio-Frequency Identification technology, enabling software to trigger a response when a mobile device enters or leaves the area. 13

14 14

15 Anti-Stigma Anti-Stigma Campaign: Tackles the stigma associated with SUDs that may prevent those at risk, family members and loved ones from seeking help. 1. Stigma associated with MAT 2. Stigma around SUDs 3. Distorted Perceptions, a person is not just a disease 15

16 Anti-Stigma PSAs Media Buy: Commercial, Cable and Public TV, radio Theater Buy Development of print materials Available for BHA, BeforeItsTooLate (BITL), Local Health Departments, Nonprofits, stakeholders & partners websites Information on naloxone: (30-second) animated video on how to administer

17 Public Awareness Additional Activities Good Samaritan Ambassadors: Advocates reaching out to families, educators, law enforcement, elected officials, active users/loved ones regarding the Good Samaritan Law Posters & print materials made available for all stakeholders Naloxone Works Campaign: Photos of real Marylanders who have saved a life by administering naloxone Transit, minor league stadiums, UMD sports programs, billboards Informational Materials: Naloxone pamphlets/cards/posters, fentanyl cards 17

18 Goal 2: Improve early identification of and intervention with opioid addiction Priority 2.2 Build capacity of health care system to identify behavioral health disorders and link patients to appropriate specialty care Key Strategy: Screening, Brief Intervention and Treatment (SBIRT) Substance Abuse and Mental Health Services Administration (SAMHSA) 5 year, $10 million grant began August 2014, to implement SBIRT in primary care and emergency departments across Maryland Purpose is to identify the misuse of substances through universal screening, brief intervention and treatment Peers assist medical staff in Emergency Departments through referral to treatment 18

19 Screening, Brief Intervention and Treatment (SBIRT) continued SAMHSA dollars provided implementation in to 10 hospitals, 3 FOHC's with 9 sites; 12 Primary Cares with 32 sites FY18 OOCC dollars expanded implementation to 15 hospitals, and pilot program in specific Detention Centers Stats as of 2/28/2018 #screened - 260,837 (69%) #screened positive - 37,135 (14%) #of those provided BI - 18,811 (51%) #of those referred - 4,665 (25%) 19

20 Goal 3: Expand Access to Services that Support Recovery and Prevent Death and Disease Priority 3.1 Improve access to and quality of evidence-based opioid addiction treatment in the community Key Strategy: BHA Buprenorphine Expansion Related Projects Three medications commonly used to treat OUD Methadone clinic-based opioid agonist that that relieves physiological opioid craving by providing a steady and stable level of medication to the brain; daily liquid dispensed only in specialty regulated clinics Buprenorphine office-based opioid agonist/ antagonist with pharmacological properties similar but different than methadone; increasing dose may not produce additional effects once reached maximal effect, decreased risk of effects such as analgesia and respiratory depression; daily dissolving tablet, cheek film, or 6-month implant under the skin Long Acting Naltrexone office-based opioid antagonist that displaces other opioids from receptors and blocks their effects; monthly injection Mechanism of Action for all 3 at mu-opioid receptor 20

21 Medication Assisted Treatment The Evidence Medication assisted treatment (MAT) for opioid use disorders is more effective than treatment without medication. Johnson, R. E., Chutuape, M. A., Strain, E. C., Walsh, S. L., Stitzer, M. L., & Bigelow, G. E. NEJM, 2000 Krupitsky, E., Nunes, E. V., Ling, W., Illeperuma, A., Gastfriend, D. R., & Silverman, B. L. Lancet, 2011 Lee, J. D., Friedmann, P. D., Kinlock, T. W., Nunes, E. V., Boney, T. Y., Hoskinson, R. A., Jr., O Brien, C. P. NEJM, 2016 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. Cochrane Database of Systematic Reviews, 2009 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. Cochrane Database of Systematic Reviews, 2014 A longer length of time in treatment with medication is more effective than a shorter time in treatment. NIDA, 2012; NIDA, 2009 ONDCP, 2014 Magura & Rosenblum, Mount Sinai Journal of Medicine,

22 Medication Assisted Treatment The Evidence The use of methadone or buprenorphine as part of a treatment program is associated with decreases in opioid overdose deaths. Auriacombe, M., Fatséas, M., Dubernet, J., Daulouède, J. P., & Tignol, J. American Journal on Addictions, 2004 Degenhardt, L., Randall, D., Hall, W., Law, M., Butler, T., & Burns, L. Drug and Alcohol Dependence, 2009 Gibson, A., Degenhardt, L., Mattick, R. P., Ali, R., White, J., & O Brien, S. Addiction, 2008 Schwartz, R. P., Gryczynski, J., O Grady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y., Jaffe, J. H. American Journal of Public Health, 2013 World Health Organization. WHO Press,

23 Medication Assisted Treatment The Evidence One or more of the medications used in treatment of Opioid Use Disorder has been associated with: Decrease in use of illicit drugs Decreased mortality Reduction in overdose deaths Improvement in health conditions Decrease in HIV rates and transmission Decrease in needle sharing Decrease in criminal activity Increased retention in treatment Increase in employment Increase in social stability (family, living situation) 23

24 Buprenorphine Expansion Overall Goals 1) Increase access to and knowledge regarding buprenorphine, including changes to DATA 2000 law. 2) Promote integration of office based buprenorphine services with public behavioral health treatment and recovery system at local level. 3) Encourage Opioid Treatment Programs to provide buprenorphine. 4) Expand use of buprenorphine in other clinical settings including emergency rooms and outpatient mental health clinics. 5) Increase integration of buprenorphine, overdose education strategies, use of telemedicine, and naloxone distribution for high risk patients in multiple clinical settings in rural and underserved areas. 24

25 Buprenorphine Regulations DATA 2000 Prescribers must apply and receive a waiver from the DEA to prescribe or dispense buprenorphine: Includes Physicians, Nurse Practitioners and Physician Assistants. Buprenorphine-Specific Education Required: Physicians must completing eight hours of required training; Nurse practitioners and physician assistants in office based settings must complete 24 hours of training. Caps on Prescribing: All prescribers are allowed up to 30 patients during first year of waiver; In second year, can apply to treat up to 100 patients; Physicians treating 100 patients for at least a year can apply to prescribe buprenorphine up to 275 patients. 25

26 BHA Buprenorphine Expansion Projects Providers Clinical Support System for Medication Assisted Treatment Implementation Program (PCSS-MIP) Buprenorphine prescribing via telehealth Outreach to PAs and NPs Jurisdictional Buprenorphine Initiatives Maryland Addiction Consultation Service (MACS ) Hospital Based Buprenorphine Initiative (HBBI) 26

27 Maryland Addiction Consultation Service - (MACS) Supports primary care and specialty prescribers of buprenorphine across Maryland in identification and treatment of opioid use disorders Services include: Access to support via free phone consultation for clinical questions, resources or referral information; Offering training and education opportunities related to opioid use disorders; Assistance with identification of addiction and behavioral health resources for patients Outcomes as of 3/19/18 include: 108 prescribers signed up 39 total calls, the majority were received by Baltimore County and City, Montgomery County and Prince George s County. 27

28 Maryland Addiction Consultation Service - (MACS) Appropriate questions for MACS? Any questions related to the initiation and maintenance of Buprenorphine for the treatment of opioid use disorders Topics may include: Initiation and maintenance of Buprenorphine Termination of Buprenorphine Psychopharmacology Alternative medication treatments Community resources and referrals 28

29 Hospital Based Buprenorphine Induction (HBBI) Services Initiates buprenorphine in Emergency Departments (EDs) for survivors of opioid overdose, and other patients with severe opioid use disorder. Collaboration between multiple partners and a growing list of hospital EDs: Behavioral Health Administration (BHA) The Mosaic group SBIRT Emergency Departments (EDs) Current Hospitals Include: Bon Secours Hospital MedStar Harbor Hospital Mercy Hospital UMMS UM Midtown MedStar Franklin Square Medstar Good Samaritan Medstar Union Memorial GBMC St. Agnes 29

30 HBBI: Evidence-Based Practice Observational study: Berg et al. Drug Alcoh Depend patients seen in Johns Hopkins adult ED with opioid withdrawal 56% were given dose of injectable buprenorphine +/- symptomatic medications 26% received only symptomatic medications 18% received no medications 8% receiving buprenorphine returned to ED w/in 30 days for drug related visit vs 17% of those receiving symptomatic treatment No incidents of precipitated withdrawal or other adverse consequences RCT: D Onofrio et al. JAMA adults screening positive for opioid use disorder (OUD) in adult ED at Yale 9% with opioid overdose 34% seeking treatment for OUD Randomized to one of 3 arms: Referral to addiction treatment Brief intervention and referral to addiction treatment Buprenorphine dose and referral to primary care within 72 hours for ongoing buprenorphine Primary outcome was engagement in addiction treatment at 30 days 30

31 HBBI: Evidence-Based Practice RCT: D Onofrio et al. JAMA 2015 RESULTS Significantly higher proportion of patients receiving buprenorphine in ED were engaged in addiction treatment at 30 days 78% in buprenorphine arm 37% in referral arm 45% in brief intervention and referral arm Greater reductions in self-reported illicit opioid use among buprenorphine group From mean 5.4 days per week to 0.9 days in buprenorphine arm From mean 5.4 days per week to 2.3 days in referral arm From mean 5.6 days per week to 2.4 days in brief intervention and referral arm 31

32 HBBI: Process and Clinical Protocol Step 1- Patient is screened using SBIRT screening and identified as having OUD and motivated for treatment. Clinical Protocol- Patient referred to Peer Recovery Coach (PRC) to assesses motivation for treatment. If motivated, refers to Medical team. Step 2- Medical team approves patient for HBBI protocol and assesses if patient is clinically able to receive buprenorphine dose in ED. If so, patient receives initial dose of buprenorphine. Clinical Protocol- Clinical Opioid Withdrawal Scale (COWS) administered by nursing, MD assesses patient for exclusion criteria (long acting opioid pain medication or pregnant). COWS of 8 or higher triggers order for buprenorphine 8 mg. Nurse administers initial dose. Step 3- Patient is Fast Tracked to MAT provider in community within 24 hours for continued buprenorphine induction. Clinical Protocol- PRC arranges appointment within 24 hours at Fast Track treatment program. Patient provided discharge summary with diagnosis of OUD and indication of dose administered. PRC follows up to determine linkage to treatment and needed support. 32

33 HBBI: Buprenorphine Waiver Not Necessary DEA Three Day Rule Exception to DATA 2000 Waiver Provides for practitioner flexibility in emergency situations to treat patients undergoing opioid withdrawal 72-hour exception allows for provider to administer up to three days of medication to treat acute withdrawal symptoms while arranging for treatment EDs generally do not allow patients to leave with medications, thus one dose is provided in HBBI under this provision 33

34 HBBI: Fast Track Treatment Programs Treatment programs that offer MAT using buprenorphine: OTP IOP/OP Primary Care Psychiatrist Partner with HBBI hospital to accept patient next day; Receive discharge summary from hospital at any time of day; Use discharge summary clinical information to obtain order for Day 2 buprenorphine induction; Enroll patient in other services as indicated. 34

35 HBBI: Buprenorphine Outcomes 35

36 Goal 3: Expand Access to Services that Support Recovery and Prevent Death and Disease Progression Priority 3.3 Increase access to a statewide infrastructure for providing harm reduction services to active opioid users Key Strategy: Overdose Survivors Outreach Program CDC funding created project FY18 OOCC funding expanded hospital ED settings Peers located in hospital emergency departments reach out to overdose survivors not immediately admitted to treatment or other services Follow up could last up to 6 months Implemented in 15 hospitals OSOP outcomes (as of 1/18): 659 patients were linked to treatment by peers with a 58% rate of treatment engagement for those referred to treatment 36

37 Goal 4: Enhance data collection, sharing, and analysis to improve understanding of and response to the opioid epidemic Priority 4.2 Establish a public health surveillance system to monitor indicators of opioid-related morbidity and mortality for informed rapid and actionable response Key Strategy: Overdose Hospital Events (OHE) & Prescription Drug Monitoring Program (PDMP) Dashboards Overdose visits County by County (OHE) Patients by number of overdose visits (OHE) Overdose visit count by month (OHE) Count by overdose visit categories by County compared to Maryland (OHE) CDS prescriptions (PDMP) 37

38 Overdose Hospital Events Dashboard 38

39 Prescription Drug Monitoring Program Dashboard 39

40 Thank You! Questions? Kathleen Rebbert-Franklin, LCSW-C Director, Health Promotion and Prevention Behavioral Health Administration Maryland Department of Health 40