Arizona s Opioid Epidemic

Transcription

1 Arizona s Opioid Epidemic Rise in Heroin Addiction and the Dangers of Fentanyl Sara Salek, MD Chief Medical Officer Shana Malone, MS Clinical Initiatives Project Manager 1

2 Disclosures None The National Opioid Influx A 4 fold increase in the quantity of Rx Opioids sold in the U.S. The U.S. makes up 4.6% of the world s population, but consumes 80% of its Rx opioids 91 opioid deaths every day! 2

3 CDC National Estimates 5 Volume: Access Ratio Enough Rx opioids were dispensed last year to medicate every Arizona adult around the clock for more than 2 weeks 6 3

4 Emerging Heroin Trends 7 Heroin and Other Substances 828,000 Americans used heroin in the past year 72.1% were also misusing Rx Opioids 4

5 Pathways to the Heroin Shift Economics Access Cartels 9 Fentanyl 10 5

6 What the Opioid Epidemic is Costing Arizona 11 Arizona Opioid-Related ED Encounters and Hospital Admissions % Increase Event Rate Per 100,000 Population % Increase EMERGENCY ENCOUNTERS HOSPITAL ADMISSIONS

7 9 8 7 Neonatal Abstinence and Newborn Drug Exposure Rates per 1,000 Births AHCCCS represented 51% of Arizona hospital births between 2008 and 2014, but was the payer for 79% of the NAS cases 218% Increase 6 245% Increase Neonatal Abstinence Syndrome (779.5) Narcotic Exposure (760.72) Cocaine Exposure (760.75) Fetal Alcohol Syndrome (760.71) Hallucinogen Exposure (760.73) 13 Number of Drug Overdose Deaths Involving Opioids, Arizona (ADHS) 500 Number of drug poisoning deaths % Increase 693.3% Increase Opioid pain relievers* (T40.2 T40.4) Heroin (T40.1) *includes methadone Year 7

8 Finding a Solution 3 Groups to Target 1. Opioid-Naïve Individuals 2. The Chemically Dependent 3. Diverters 8

9 3 Strategies to Implement 1. Harm Reduction 2. Prescribing/Dispensing Practices and Patient Ed 3. Access to MAT Why Naloxone? The obvious it saves lives! 335 reversals between Jan-March 2017 Creates awareness Community distribution Someone understands and cares Access to additional services and resources Pipeline to treatment referral 18 9

10 Strategic Plan STRATEGY #1: Enhance Harm Reduction Strategies to Prevent Overdose o GOAL #1: Provide education and training on Naloxone to prescribers, pharmacists and patients o GOAL #2: Increase access to Naloxone. 19 WHY Opioid-Naïve Individuals? CDC MMWR, March

11 High Risk Populations Criminal Justice population American Indians Former users Veterans High MEDDs and Polypharm Trauma, depression, anxiety Why Target Polypharm? BMJ, March

12 Elevated Misuse in MH Population (NSDUH, 2015) 23 Specifically Those with Depression 24 12

13 And, Suicidal Thoughts 25 Strategic Plan STRATEGY #2: Promote responsible prescribing and dispensing policies and practices o GOAL #1: Reduce the number of opioid-naïve patients unnecessarily started on opioid treatment o GOAL #2: Improve care processes for chronic pain and high-risk patients

14 Sign Up and USE the CSPMP Ensure Patient Safety Limit Liability Now Easier than Ever with Delegate Option Facilitate Use of Best Practices 14

15 Register for FREE CME Educate Patients 15

16 Project ECHO 31 Screening and Assessment Substance Use Mental Health 32 16

17 Co-Prescribing Naloxone >90 MEDDs Any combination of opioids with benzos, muscle relaxers and sleep medication Education and instructions key 33 Why MAT? Improves treatment retention Decreases opioid use Reduces risk of mortality 34 17

18 Strategic Plan STRATEGY #3: Enhance Access to Medication Assisted Treatment o GOAL #1: Assess statewide capacity of MAT providers available patients o GOAL #2: Increase access to integrated MAT for patients 35 Treatment of Opioid Use Disorder Psychosocial Pharmacotherapy o Short term withdrawal o Maintenance treatment 18

19 Goals of Treatment Risk reduction vs. complete abstinence Overarching themes o Pro-social behavior Employment Caring for family o Emotional and physical health o Avoid justice involvement 37 Reward Pathway 38 19

20 Opioid Effects Acute Chronic Overdose Euphoria Physical dependence Nonresponsive Analgesia Psychological dependence Pinpoint pupils Emesis Energy changes Bradycardia Constricted pupils Constipation Hypotension Slowed respirations Death Drowsiness to altered consciousness *Adapted from Handbook of Office Based Buprenorphine Treatment of Opioid Dependence 2011 American Psychiatric Publishing, Inc. Opioid Withdrawal Symptoms Pupillary dilation Tachycardia Diaphoresis Gooseflesh skin Runny nose/tearing Tremor Yawning Anxiety/irritability Restlessness Bone/joint aches GI upset 20

21 Treatment of Opioid Use Disorder: Maintenance Pharmacotherapies Full agonist therapy with methadone Partial agonist therapy with buprenorphine Antagonist therapy with naltrexone Different mechanisms for MAT 42 Jones, H. E. (2004), 'Practical considerations for the clinical use of buprenorphine', Science & Practice Perspectives 2, no. 2, pp

22 Summary Chart: MAT Buprenorphine Methadone Naltrexone Indications OUD, Pain OUD, Pain OUD, AUD Pharmacology Partial agonist Agonist Antagonist Common Side Effects HA, constipation, nausea, sweating Constipation, sweating, insomnia HA, fatigue, pain, N/V DEA Schedule III II Non schedule Where available Office based Only through OTP Office based Frequency One month supply with refills for up to 6 months Earn up to 28 takehome doses qmonth after 3 drug free years in treatment Injections once monthly 43 Methadone Critique Assumptions: o Methadone is just as risky as illicit opioid use o Methadone is not hope-based o Chronic therapy with methadone limits freedom 44 22

23 Methadone Tx Outcomes 70% reduction in the risk of mortality for patients on methadone maintenance compared to untreated heroin use disorder Deaths among heroin users in and out of methadone treatment, AU Desmond, DP, Maddux, JF SOJ Maint Addict. 2000; 1: Methadone Tx Outcomes Cochrane 2009 Review Methadone is an effective maintenance therapy compared to non-opioid based treatment o Retains patients in treatment o Decreases heroin use Did not show a statistically significant superior effect on criminal activity or mortality evidence on o Reduction of criminal activity and mortality from clinical trials is lacking calling for an additional systematic review of observational studies 46 Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. AU Mattick RP, Breen C, Kimber J, Davoli M SO, Cochrane Database Syst Rev

24 Methadone-related deaths on the rise Trend over past two decades Related to increased availability of methadone tablets used for treatment of pain 47 Buprenorphine Effectiveness 2014 Cochrane meta-analysis o Improved treatment retention (any dose of buprenorphine) o Reduced opioid use (16 mg buprenorphine) Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. AUMattick RP, Breen C, Kimber J, Davoli M SOCochrane Database Syst Rev

25 Buprenorphine Overview Lower abuse potential o Buprenorphine/naloxone combination product to prevent abuse/diversion (naloxone only active if injected) Greater safety in overdose compared with opioid full agonists o Ceiling effect at higher doses Methadone vs. Buprenorphine for Opioid Dependence Study of 16,434 individuals o 4x rate of mortality from overdose associated with methadone compared with buprenorphine Comparing overdose mortality associated with methadone and buprenorphine treatment. AUBell JR, Butler B, Lawrance A, Batey R, Salmelainen P SO. Drug Alcohol Depend. 2009;104(1 2):

26 Naltrexone Most effective in patients who are: o Highly motivated and/or o Legally mandated to receive treatment, and/or o Medication is closely supervised Risks associated with an opioid overdose when patients attempt to overcome blockade 51 Naltrexone Injection Effectiveness: Criminal Justice Open-label, randomized trial 24-week course with usual treatment among adult criminal justice offenders Rate of opioid relapse lower than that with usual treatment during 24 week trial 1 year after treatment ended: effects waned Extended Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson RA Jr, Wilson D, McDonald R, Rotrosen J, Gourevitch MN, Gordon M, Fishman M, Chen DT, Bonnie RJ, Cornish JW, Murphy SM, O'Brien 52 CP N Engl J Med Mar;374(13):

27 Solutions Risk vs benefit Reality is level of gray No one size fits all 53 Stigma and Access to Healthcare How we talk about things impacts the way we think about things and vice versa Improved understanding that opioid use disorder is a complex interplay of biology and environment will decrease stigma and increase access to healthcare 27

28 Medical Community Solutions Open, honest discussions.are needed to examine assumptions about opioid addiction, the historical context of its treatment, and associated ideologies as a way of bridging the divide around MAT. Patients deserve the opportunity to make a well-informed choice about which path they take to [their] recovery Ask the PCSS MAT Experts: Addressing Challenging Issues in Addiction Medicine: "Abstinence Based" Treatment Centers based treatment centers 55 Thank You Shana.Malone@azahcccs.gov 56 28