OHSU. Vermont s Response to the Opioid Crisis Alumni Scientific Session Dr. Harry Chen Commissioner of Health (former)

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1 Vermont s Response to the Opioid Crisis Alumni Scientific Session Dr. Harry Chen Commissioner of Health (former) May 12, 2017

2 The Problem Opioids are powerful and useful pain killers. Opioids are highly addictive. Opioid overdose and addiction is a growing public health problem. Prescribers play a role in the supply and use of opioids in the treatment of pain and addiction in our communities.

3

4 Rolling Stone Magazine 4/3/2014

5 The distribution of morphine consumption in 2009 was highly disproportionate to the general population distribution around the world. SOURCE: International Narcotics Control Board. 5

6 SOURCE: International Narcotics Control Board. 6

7 States with more opioid pain reliever sales tend to have more drug overdose deaths Death rate, 2011, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA s Automation of Reports and Consolidated Orders System 7

8 Doctors are the most common source of opioids for most frequent nonmedical users. SOURCE: Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of pastyear nonmedical use: United States, JAMA Internal Medicine

9 The higher the morphine milligram equivalent, the higher the overdose death hazard. SOURCE: JAMA 2011;305:

10 Patients receiving high doses of opioid pain relievers account for disproportionate share of overdoses. 100% multiple doctors, high doses 90% multiple doctors, one doctor, high dose 80% high doses 70% 60% 50% one doctor, lower dose 40% one doctor, high dose 30% 20% 10% 0% patients receiving opioid pain relievers one doctor, lower dose patients overdosing with opioid pain relievers SOURCE: CDC Grand Rounds: Prescription Drug Overdoses a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);

11 an epidemic of suicides and afflictions stemming from substance abuse: alcoholic liver disease and overdoses of heroin and prescription opioids.

12 All-cause mortality, ages for US White non-hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE). Anne Case, and Angus Deaton PNAS 2015;112: by National Academy of Sciences

13 Mortality by cause, white non-hispanics ages Anne Case, and Angus Deaton PNAS 2015;112: by National Academy of Sciences

14 Overall Opioid 2015 Death Rate by State Source: CDC Wonder as compiled by the Washington Post

15 Vermont is the Only Northeastern State without a Statistically Significant Increase in Drug Overdose 2014 to 2015 Source: CDC/NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs.

16 New England Drug Overdose Deaths Connecticut Maine 25 Massachusetts 20 New Hampshire Rhode Island 15 Vermont 10 Deaths per 100, Source: CDC/NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs

17 Vermont Drug Poisoning Estimated Deaths by County (All Drug Poisoning Deaths) Source: Centers for Disease Control and Prevention, Drug Poisoning Mortality: United States, Vermont s 2014 age adjusted rate of drug poisoning deaths is the same as the U.S. average at approximately 14.7 per 100,000 Vermonters. January 2016

18 Drug-Related Fatalities Involving Opioids Total number of accidental and undetermined manner drug-related fatalities involving an opioid (categories not mutually exclusive) Total opioid Rx opioid Heroin Fentanyl Source: Vital Statistics System

19 Key Surveillance Needs Respond to emerging issues

20 Emergency Department Discharge Data Emergency Department Discharge Rate per 100,000 People for Opioid Overdose, by Type of Opioid and Year Vermont Residents at Vermont Hospitals Other opioids Heroin Source: Vermont Uniform Hospital Discharge Data Set

21 Nationally, over half of those who misused a prescription pain reliever got it from a friend or relative. Source: National Survey on Drug Use and Health,

22 Non-medical use of prescription pain relievers in Vermont Percent of Vermont population reporting non-medical use of pain relievers in the past year by age in years Source: National Survey on Drug Use and Health,

23 Heroin use among high school students remains low Percent of high school students reporting heroin use within their lifetime by year Source: Youth Risk Behavior Survey, 2013 and

24 Opioid Misuse Young Adult Survey* & College Health Survey Percent of young adults who report opioid misuse in the past year by data source Young Adult Survey *Young Adult Survey conducted by the Pacific Institute for Research and Evaluation under a contract with VDH College Health Survey Source: Young Adult Survey and College Health Survey 24

25 In 2012, Vermont had a relatively low number prescriptions per person 25

26 Number of Prescriptions by Drug Type and Year Total Number of Controlled Substance Prescriptions by Drug Type and Year Opioids Sedatives Stimulants Adjusted Opioids 601, , , , , , , , , , , , , , , , , , , Note: The 2015 Annual Report reflects the first full year of VPMS data with tramadol reclassified from a Schedule V to a Schedule IV drug. Its inclusion in VPMS data due to this reclassification resulted in an increase of 82,992 opioid prescriptions being reported to VPMS Additionally, the White River Junction Veterans Affairs Medical Center began uploading to VPMS in March of It uploaded 19,541 opioid prescriptions in Had these two new data sources not been provided to VPMS in 2015, the number of opioid prescriptions would have decreased for the first time since (See the Adjusted Opioids trend line.) 26

27 Prescription histories of Individuals with opioid-related accidental fatalities (ORAF) In 2015, 68 of 75 ORAF individuals had controlled substance prescription histories Of the 68, 81% received high dose (>90 MME) analgesics in the period before their deaths ORAF s with an opioid prescription in the year prior to fatality received average of 261 days supply in that year. % of ORAF with > 90 MME Opioid Rx by Time Elapsed Before Death Vermont Department of Health Source: Vermont Prescription Monitoring System and Vital 27Statistics

28 For every 1 fatal opioid overdose in VT there are: people receiving at least one rx for analgesics 1,482 nonmedical rx pain reliever users needle exchange members 64 EMS overdose calls 18 people receiving at least one MAT service for OUD community opioid reversals emergency department visits for opioids infants born exposed to opioids 5 3 2

29 Actions to Address Opioid Drug Abuse Education Tracking and Regulation/Enforcement Identification verification at Prescriber Monitoring pharmacies education Vermont Prescription Law enforcement training on Community Drug Monitoring System prescription drug misuse and education (VPMS) diversion Naloxone Unified Pain Management distribution Regulation Treatment Options Keeping medications safe at home Care Alliance for Opioid Addiction Proper Medication Disposal Proper medication disposal guidelines consistent with FDA standards Community take-back programs Most Dangerous Leftovers Campaign Regional Treatment Centers Outpatient and residential treatment at state-funded treatment providers Harm Reduction 29

30

31 Regulation MAT Rule Based on DATA 2000 Unified Pain Management Rule (Chronic) VPMS (prescription monitoring) Patient contract Urinalysis requirement Pill counts Referral for risk Acute Pain Rule

32 The Problem As many as four out of five heroin users begin by abusing prescription drugs Of those who abuse prescription opioids, seven out of 10 received these drugs through methods of diversion Opioids are overprescribed. They are prescribed: Too often At too high a dose For too long One in four become addicted. One in 550 die from their opioids Prescribers play a role in the supply and use of opioids in our and use of opioids in communities.

33

34

35 Patient-level surveys of opioid use after surgery Dartmouth Hitchcock researchers examined opioid prescribing patterns after general surgery outpatient procedures. Results: An average of only 28% of pills were used To satisfy 80% of patient needs, could reduce Wide variation in quantity provided for each operation prescription amounts by 43% 1: Hill M, McMahon M, Stucke R, & Barth R. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Annals of Surgery. 2016; doi: /SLA

36 Patient-level surveys of opioid use after surgery UVM study (Nov. 2016), after general and orthopedic surgery, same wide variation found even within a practice. Results: 7% did not receive an opioid Of the 93% who received an opioid 12% did not fill the prescription 30% that filled the prescription didn t use any The overall median proportion used = 26%

37 New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults Chad M. Brummett, MD1,2; Jennifer F. Waljee, MD, MPH, MS2,3; Jenna Goesling, PhD1; et al JAMA Surg. Published online April 12, doi: /jamasurg Conclusions: In a cohort of previously opioid-naive patients, approximately 6% continued to use opioids more than 3 months after their surgery, and as such, prolonged opioid use is a common postsurgical complication. New persistent opioid use is not different among patients who underwent minor and major surgical procedures, thereby suggesting that prolonged opioid use is not entirely due to surgical pain.

38 Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use Michael L. Barnett, M.D., Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D. N Engl J Med 2017; 376: February 16, 2017DOI: /NEJMsa department, and rates of long-term opioid use were Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers.

39 Percent of people getting 50% pain relief (from acute postop pain) 1/NNT From Cochrane Reviews Two 5 mg Percocet pills Ibuprofen 200mg Ibuprofen 400 mg Oxycodone 15 mg Acetaminophen 500 mg Ibu acet 500 Source: Don Teater MD

40 Universal Precautions First consider non-opioid and nonpharmacologic treatments Upon first prescription prescribers must: discuss risks including safe storage and disposal provide a patient education sheet, and receive an informed consent for all first opioid prescriptions Co-prescribe naloxone for prescriptions over 90 MME or if also on benzodiazepines Check the prescription monitoring system for everyone s first prescription exceeding 10 pills or a replacement prescription

41 Opioid Prescribing for Acute Pain First prescription to opioid naïve patients: Consider non-opioid treatment Prescribe minimum needed for pain 350 MME (50 MME per day for 7 days) limit Ensure a safe transition of care to patients PCP Avoid long-acting opioids

42 Opioid Prescribing for Minors Teens who used opioids for legitimate reasons in high school had a 33% increased risk for future misuse compared to their peers. 1 Consult with pediatrician before prescribing in ED Opioids as last resort for minor injuries Limits the first prescription to a total of 72 MME (24 MME for 3 days) 1 Miech R, Johnston L, O Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015;136(5):e1169-e1177.

43 Opioid Prescribing for Chronic Pain Universal precautions apply Informed Consent, Controlled Substance Treatment Agreement to be repeated annually Requires pain management plans and ongoing assessments of opioid effectiveness Sets a trigger for revaluation at 90 MME Stable patients must be evaluated at least every 90 days Co-prescribe naloxone for prescriptions over 90 MME or if also on benzodiazepines

44 People seek treatment for opioid addiction much sooner after first use than with alcohol Number of admissions Alcohol Opiates Opioids Alcohol 700 Average Elapsed Time 8.2 +/- 7 years /- 12 years Elapsed Time (Years) Between Age of First Use and Age at Treatment Admission for Daily Users of Opioid and Alcohol ( ) Elapsed Time (Years) Source: Alcohol and Drug Abuse Treatment Programs, admissions

45 Effectiveness of Medication Assisted Treatment Several studies have clearly demonstrated MAT is effective across a number of behavioral dimensions compared to placebo or psychological treatment alone: Reduced opioid use (including IVDU) Increased engagement and retention in treatment Reduced morbidity and mortality Improved social functioning Reduced criminal activity Reduced transmission of infectious diseases 45 45

46 Hub and Spoke Model Results for Patients + An established physician-led medical home + A single MAT prescriber + A pharmacy home + Access to existing Community Health Teams + Access to Hub or Spoke nurses and clinicians + Linkages between Hubs and primary care Spoke providers in their areas

47 Vermont has one of the highest rates of treatment capacity Rate of Past Year Opioid Abuse or Dependence* and Rate of Medication Assisted Treatment Capacity with Methadone or Buprenorphine Source: NSDUH Source: N-SSATS *Opioid abuse or dependence includes prescription opioids and/or heroin Source: AJPH 2015; 105(8):e

48 The number of people using heroin at treatment admission is increasing faster than for other opioids Number of people treated in Vermont by substance and Fiscal Year 7,000 Alcohol Marijuana/Hashish Heroin/Other Opioids All Others 6,000 5,000 4,000 3,000 2,000 1, Source: Alcohol and Drug Abuse Treatment Programs

49 While more heroin users inject than prescription drug users, the percent has remained fairly stable Primary Heroin Primary Rx Opiates 80.5% 81.9% 77.2% 75.7% 76.7% 73.1% 72.6% 74.8% 74.6% 76.5% 76.1% 24.8% 21.6% 18.5% 20.7% 21.6% 21.0% 23.3% 24.9% 25.7% 22.2% 23.2% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of individuals treated for primary diagnosis of opioid misuse who are injection drug users by type of opioid and year Source: Alcohol and Drug Abuse Treatment Programs

50 People Treated for Opioid Abuse or Dependence by Age and Fiscal Year Number of People Treated for Opioid Abuse by Age and Fiscal Year ,839 < , , ,381 1,147 1, Source: Alcohol and Drug Abuse Treatment Programs

51 IV Drug Use at Admission OP/IOP/Residential Treatment 35% 30% 30% 26% 25% 20% 20% 16% 15% 13% 13% 13% 11% 12% 12% 10% 5% Percent of People with IVDU for Primary, Secondary, or Tertiary Substance of Abuse by CY 0% Source: Alcohol and Drug Abuse Treatment Programs 51

52 As the total number of clients in treatment increased, the number of people waiting for services remains flat Census Waiting Jan-14 Feb-14 Mar-14 Number of People in Hubs and Waiting for Hub Services Over Time Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Source: Alcohol and Drug Abuse Treatment Programs 52

53 MAT Evaluation: Preliminary findings Using Vermont Medicaid data, analysis shows: Longer Medication Assisted Treatment corresponds to Individuals with an opioid dependent diagnosis receiving MAT have lower medical care costs than those who have an opioid dependent diagnosis and are receiving non-mat substance abuse treatment lower non-treatment related medical care costs 53

54 Patient functioning at hub discharge Of those completing treatment or transferring to another level of care, 75% show overall improved functioning at discharge Those who leave treatment for other reasons, such as leaving against medical advice, incarceration, or are administratively discharged, only 34% have improved functioning 54

55 55

56 The total number of needles dispensed almost hit 1 million Total number of syringes dispensed by year 999, , , , , ,095 1,200,000 1,000, , , , , Source: Vermont Syringe Exchange Programs 56

57 Vermont Syringe Exchange Programs Provision of sterile syringes and other injection supplies Safe disposal of used syringes (removal of used syringes from the community) Safer sex supplies and education Overdose prevention education and resources Referrals for substance abuse treatment Provision of harm reduction options while injection drug users prepare for or wait for treatment HIV and hepatitis C testing and referrals for follow up medical care if needed Referrals for recommended vaccines 57

58 Administration of Naloxone 58

59 Naloxone Number of doses dispensed by client type, quarter and year New Returning Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Number of reports of naloxone use in response to a perceived overdose incident Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Apr-Jun 2015 Jul-Sep 2015 Oct-Dec 2015 Jan-Mar 2016 Apr-Jun 2016 Source: Naloxone Pilot Program 59

60 Improved treatment and screening have helped to identify more infants exposed to opioids Source: Vermont Uniform Hospital Discharge Data Set 60

61 Change in Crimes/100,000 in Vermont Violent Property Murder Forcible Rape Robbery Aggravated Assault Burglary Larceny-Theft Vehicle Theft Federal Bureau of Investigation Uniform Crime Report

62 In Summary Vermont is putting in place many of the prevention, intervention, treatment and recovery options that could help turn the tide on the opioid crisis. Vermont is doing better than much of the country in substance abuse treatment, harm reduction and data collection. While the problem continues to increase, there are small signs of hope: Large parts of the state do not have wait lists for treatment Deaths from prescription opioids appear to be flattening * Naloxone is getting into the hands of those who need it most Youth use is trending downward over time

63 Thank you Source: Harry Chen, M.D.

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