Vermont's Opioid Crisis and Response to the Crisis

Transcription

1 Vermont's Opioid Crisis and Response to the Crisis Richard A. Rawson, Ph.D., Research Professor UVM Center for Behavior and Health Emeritus Professor UCLA Department of Psychiatry March 2018

2 The opioid crisis

3 Every 20 minutes!!!

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5 Opioids 5

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7 A lethal dose of carfentanil 1/100 th of the amount shown next to the penny.

8 Increased use of heroin/fentanyl Fentanyl is a very powerful synthetic opioid used for very severe pain. Its use on the street has increased dramatically in the past 4 years. In 2015, in some parts of New England, over 80% of the samples of heroin contained fentanyl. In over 20% of these samples, the only drug detected was fentanyl. In the summer of 2016, in some areas (southern Ohio; Barre, Vermont), overdoses from carfentanyl have been reported.

9 Opioids Differ Drug Duration Potency Methadone hours **** Heroin 6-8 hours ***** Oxycontin 3-6 hours ***** Codeine 3-4 hours * Demerol 2-4 hours ** Morphine 3-6 hours *** Fentanyl 2-4 hours ********* Chart from OOD Prevention & Reversal Trainers Manual-BPHC

10 Opioids: What are they? Poppy plant Papaver somniferum Opiate: derivative of opium poppy Morphine Codeine Opium Opioid: any compound that binds to opiate receptors Semisynthetic: Heroin; Hydrocodone; Hydromorphone; Oxycodone; Oxymorphone; Buprenorphine Synthetic: Fentanyl, Methadone, Tramadol)

11 Opioids: What do they do? Description: Opium-derived or synthetic compounds that: 1. are usually prescribed to treat pain; 2. reduce the signaling of pain messages to the brain and thereby reduce pain. 3. They have powerful effects in the brain by acting on opioid receptors to produce morphine-like effects. 4. Can relieve symptoms during withdrawal from morphine addiction. Route of administration: Intravenous, smoked, intranasal, oral, intrarectal, and implantable 11

12 Acute effects of opioids Euphoria Pain relief Suppresses cough reflex Drowsiness and lethargy Sense of well-being Depression of the central nervous system (mental functioning clouded) Pupil constriction Slurred speech Respiratory depression and death 12

13 Long-term effects of opioids Fatal overdose Collapsed veins (intravenous use) Infectious diseases Higher risk of HIV/AIDS and hepatitis Infection of the heart lining and valves Pulmonary complications & pneumonia Respiratory problems Abscesses Liver disease Low birth weight and developmental delay Constipation Cellulitis 13

14 Consequences of opioid use Increased tolerance - need for increased amounts of opioids for the same effect Dependence - the experience of withdrawal symptoms when opioids are stopped Progression, as a result of increased tolerance and dependence, to more potent opioids and methods of administration

15 Other long term effects of opioids Disrupt family and community life Impair work performance; often unreliability leads to job loss and unemployment. Need for drugs to avoid withdrawal drives illegal behavior and crime. Preoccupation with getting and using opioids leads to parental inattention/negligence. Loss of self-esteem, self-respect and a sense of hopelessness.

16 Signs of acute opioid use Sedation, sleepiness Slurred speech Euphoria Respiratory depression Small pupils Nausea, vomiting Itching, flushing Constipation

17 Signs of chronic opioid use Weight loss Erratic behavior Secretive behavior/lying/stealing Poor hygiene Irresponsibility/work problems Poor child care/inattention Acne/skin problems/needle marks Cycles of emotionality/blunted emotion

18 Opioid withdrawal symptoms Severe anxiety and agitation (In many individuals, the severity of this reaction approaches a serious panic disorder) Low tolerance to discomfort and dysphoria Drug-seeking behaviour (seeking medication to reduce symptom severity) Muscle cramps/spasms/aches Abdominal cramps/diarrhea Insomnia Chills

19 Opioid receptors in the brain

20 Effects of opioids on the brain Opioids are highly addictive. Chronic opioid use changes the brain. Brain cells can become dependent to the extent that users need it in order to function in their daily routine. Opioids initially cause a rush of pleasure. Opioids slow down the way you think, slows down reaction time, and slows down memory.

21 Opioid overdose

22 Signs of an overdose Bluish or grayish tint to the skin and lips Cold, clammy skin Shallow breath, infrequent breath or no breath Deep snoring or gurgling Not responsive to loud sound or other stimuli, such as a sternal rub Slow heart beat or pulse

23 When overdoses happen Depending on the opioid may happen within minutes or hours Or may happen quickly when fentanyl is involved After periods of abstinence (after treatment stay, hospitalization, incarceration) New city/residential location New dealer Post incarceration New route of administration

24 Vermont s Response: Increase access to Harm Reduction and Treatment Services

25 Vermont s response Vermont is the first, and presently, the only state that has comprehensively mobilized the public health and health service systems to reduce fatalities from and consequences of opioid use. In brief, the response has been to: 1. Rapidly scale up services to reduce overdose death by distributing naloxone (Narcan) 2. Make clean needles available to prevent infections (heart valve, Hepatitis C and HIV. 3. Rapidly scale up medication-assisted treatment and other treatment and recovery services and make them available throughout Vermont.

26 Naloxone-narcotic antagonist Used to counteract life-threatening depression of the central nervous system and respiratory system. Non-scheduled. Non-addictive. Works only if opioids are present. No abuse potential. Can be injected or used nasally. Wears off in minutes.

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28 Narcan nasal spray Adapt Pharma Partnership through the Clinton Health Matters Initiative-Free to all high schools and colleges in the U.S. Local & state government agencies $75.00 per dual pack. Without a prescription $ through a local pharmacy.

29 Naloxone auto-injector Designed to be used by people who do not have medical training Includes verbal instructions to guide its use When pressed against the thigh, the needle automatically injects, delivers medicine, and retracts Contains one 0.4 mg dose of naloxone

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31 Syringe exchange participation 6,000 Total number of syringe exchange members by year 5,000 4,000 3,749 4,315 4,860 3,000 2,000 1,612 2,072 2,802 1, Vermont Department of Health

32 April 2017

33 Treatment

34 The number of individuals using heroin at treatment admission is increasing faster than for other opioids/synthetics Source: Alcohol and Drug Abuse Treatment Programs

35 Medication-assisted treatment

36 NIH Consensus Statement on the Effective Medical Treatment of Opiate Addiction, 1997 Opioid dependence is a medical disorder: (Not a problem of motivation, willpower, or strength of character) Continuous exposure to opioids induces pathophysiologic changes in the brain. Opiate dependence is a brain-related medical disorder that can be effectively treated with significant benefits

37 The Global Response: UN and WHO Support for Maintenance Treatment WHO / UNODC / UNAIDS position paper: Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention Opioid maintenance treatment is an effective, safe and cost-effective modality for the management of opioid dependence. Repeated rigorous evaluation has demonstrated that such treatment is a valuable and critical component of the effective management of opioid dependence and the prevention of HIV among IDUs.

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39 Excerpts from Surgeon General s Report (2017) Well-supported scientific evidence shows that medications can be effective in treating serious substance use disorders, but they are underused. Multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation

40 Excerpt from President Obama s June 2016 speech on the opioid crisis Medication-assisted treatment with drugs like methadone and buprenorphine is a key component of my administration's attack on the opioid epidemic. These drugs are used in conjunction with behavioral treatment to help manage an addict's recovery and ease withdrawal from opioid drugs.

41 Why Not Detoxification (treatment of acute withdrawal symptoms)? POST-DETOXIFICATION RELAPSE RATES APPROACH 100% WITHIN THE FIRST 90 DAYS FOLLOWING COMPLETION OF DETOXIFICATION.

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43 There is extensive evidence supporting methadone and buprenorphine (Subboxone) treatment

44 Methadone Dolophine Methadose

45 Buprenorphine Formulations Sublingual administration Subutex (Buprenorphine) -2mg, 8mg Suboxone (4:1 Bup:naloxone) -2mg/0.5 mg, 8mg/2mg Dose: 2mg-32mg/day

46 Crime Among 491 Patients Before and During MMT at 6 Programs 300 Crime Days Per Year Before TX During TX 0 A B C D E F Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

47 Vermont hub and spoke treatment system for opioid use disorders

48 Hub and Spoke Model Goals + 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

49 HUBS Serve as referral center for SPOKES Higher level of service with daily dosing of medications Witnessed urine testing On site counseling and groups Address mental health issues Address medical issues, especially pain Conversion to methadone if needed from Suboxone

50 SPOKES All community Suboxone providers were eligible to become SPOKES Allowed for enhanced services to be provided to offices with linkages to their regional HUBS if needed Goal was to provide enhanced services for better management of these patients with better outcomes

51 MAT team MAT (Medication Assisted Treatment) Team is 1 FTE Case Manager and RN per 100 Suboxone patients and a prescribing physician Paid for by Federal matched health care dollars as part of Chronic Care Initiative What many Suboxone physicians had been asking for to help increase the number of patients they could serve May serve a few practices and not be on site

52 Number of people receiving MAT and number waiting for services 7000 Hub Spoke Number Waiting for Hub Source: Hub Census and Waitlist, Medicaid Claims for Spokes Vermont Department of Health

53 Fatalities

54 New England - Overdose deaths 40 Drug Overdose Deaths per 100,000 by State 35 Deaths per 100, Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Vermont Department of Health Source: CDC/ NCHS

55 Hub and Spoke Evaluation Project Results

56 The H&S evaluation: Change in opioid use Opioid use of in-treatment participants 90 Number of Days of Use days before treatment 90 days before interview 10 0 Any Opioid Use Prescription Opioids without a Doctor's Prescription Illicit Opioids Opioid Treatment Medication, without Prescription Opioid Injection

57 The H&S evaluation: Medical utilization and overdose Medical utilization Overdose # of times % 90 days before treatment 90 days before interview 25% 25% % overdose in the past 90 days 20% 15% 10% 5% 0 ER Visits (# of times) Overnight Hospital Stay (# of times) Outpatient or Doctor Visits (# of times) 0% 0% 90 Days Before Treatment 90 Days Before Interview

58 The H&S evaluation: Criminal justice measures Criminal justice involvement Days of Illegal Activities 5 35 Number of Days days before treatment 90 days before interview Number of Days Stopped or Arrested by Police Incarcerated 0 90 Days Before Treatment 90 Days Before Interview

59 The H&S evaluation: Closing thoughts The Vermont Hub-and-Spoke System of Care for Opioid Use Disorders is an innovative and constructive public health response to the opioid epidemic of the 21 st century in the United States. The H & S system has markedly expanded access to MAT and improved participants lives. The services provided within this model have saved many lives and have allowed many Vermonters to discontinue opioid use and improve their lives.

60 Thank you Richard Rawson