Mark Hurst, M.D., Medical Director

Transcription

1 Mark Hurst, M.D., Medical Director

2 50 County Boards serving all 88 counties 49 combined boards (ADAMH: Alcohol, Drug abuse and Mental Health) State funding Local levy funding that varies greatly Ohio Department of Mental Health and Addiction certified agencies: 300 addiction treatment agencies 400 mental health agencies Many dually certified 2

3 Pre-Medicaid expansion: Boards responsible for Medicaid match until 2011 Large uninsured population of individuals with mental illness and addictions Boards responsible for care of un-insured both inpatient (state hospital) and outpatient Carved-out Medicaid BH benefit Managed care plans responsible for inpatient coverage and medications Fee-for-service responsible for all other services 3

4 Post-Medicaid expansion: Medicaid match became state responsibility (freeing some levy funds) Boards no longer responsible for state hospital bed days Boards retained responsibility for outpatient care of uninsured (but fewer uninsured) Medicaid BH benefit still carved out Carve-in July

5 Athens Region Lawrence Meigs Gallia Washington Monroe Scioto Adams Brown Hamilton Butler Warren Clinton Highland Jackson Ross Vinton Athens Preble Greene Fayette Madison Clark Miami Darke Champaign Franklin Pickaway Fairfield Hocking Mercer Auglaize Shelby Logan Union Hardin Allen Van Wert Paulding Putnam Hancock Wyandot Marion Delaware Morrow Seneca Sandusky Ottawa Lucas Fulton Williams Henry Wood Defiance Erie Huron Lorain Wayne Medina Cuyahoga Summit Knox Holmes Licking Coshocton Muskingum Tuscarawas Guernsey Perry Morgan Noble Belmont Harrison Carroll Columbiana Stark Portage Mahoning Trumbull Ashtabula Geauga Lake Crawford Region Lawrence Gallia Scioto Adams Hamilton Pike Jackson Vinton Athens Madison Miami Darke Fairfield Hocking Mercer Auglaize Shelby Union Hardin Allen Putnam Hancock Wyandot Marion Delaware Seneca Sandusky Ottawa Lucas Wood Erie Huron Holmes Guernsey Perry Morgan Noble Belmont Harrison Clermont Jefferson Richland Crawford Ashland Montgomery Northwest Northcoast Summit Heartland Twin Valley Appalachian 5

6 Six hospitals across the state with 1,077 beds * Major shift to acute and forensic care Very busy occupancy rate of 95-98% every day Median LOS of 12 days for civil patients 30-day readmission rate steady at 7.9% for last 12 months Fewer than 45 civil patients with a LOS of 180 days or more * Bed total does not include the 52 beds at the maximum security Timothy B. Moritz forensic unit 6

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9 Civil patients (includes jail transfers) Screened for admission by local board/designee When determined to meet criteria, hospital is contacted to arrange admission Admission criteria: They must have a mental illness: Mental illness means a substantial disorder of thought, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. ORC AND.. 9

10 Their symptoms are of sufficient severity that they cannot be safely treated in a setting other than an inpatient facility, namely: Dangerous to self Dangerous to others Unable to care for basic needs Represents a threat to rights and privileges of others 10

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12 Ohio Prescription Opioid Retail Sales Grams per 100,000 Population 70,000 60,000 50,000 40,000 30,000 20,000 10, Total Opiods 20,03 21,00 22,01 25,76 27,25 29,91 33,74 39,19 39,54 44,04 48,13 51,34 55,51 57,64 60,61 57,17 52,31 48,81 46,94 Hydrocodone 2,887 3,182 3,727 4,391 4,678 5,422 6,148 6,536 7,005 7,742 8,977 9,598 10,37 10,51 11,48 10,71 9,963 9,394 8,417 Oxycodone 2,046 3,003 4,635 7,619 9,010 9,979 12,55 15,47 15,89 18,80 20,72 22,60 25,21 26,32 25,72 24,46 22,64 21,30 20,62 12

13 Unintentional Drug Overdoses & Distribution Rates of Prescription Opioids in Grams per 100,000 population, Ohio, Unintentional drug overdose death rate per 100, , Opioid distribution in Grams per 100,000 population 4 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 Opioid analgesic grams dristributed Unintentional drug overdose death rate population Sources: 1. Ohio Vital Statistics; 2. DEA, ARCOS Reports, Retail Drug Summary Reports by State, Cumulative Distribution Reports (Report 4) Ohio, Calculation of oral morp 0 13

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15 Prevention Early intervention Treatment Life-saving measures Interdiction 15

16 Increased admissions for patients with Opioid use disorders: Dual Diagnosis: Severe mental disorder and opioid use disorder Primary opiate use disorder with severe psychiatric symptoms (suicidal) secondary to effects of drug or social situation Opiate use disorder with malingered psychiatric symptoms (suicidal, homicidal) to access treatment for SUD 16

17 OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES ADMISSIONS FOR FISCAL YEAR 07 TO All Opioid* FY'07 FY'08 FY'09 FY'10 FY'11 FY'12 FY'13 FY'14 FY'15 FY'16 *Information Unavailable for FY'16 All OPIOID 17

18 Lawrence Meigs Gallia Washington Monroe Scioto Adams Brown Clermont Hamilton Butler Warren Clinton Highland Pike Jackson Ross Vinton Athens Preble Greene Fayette Madison Clark Miami Darke Champaign Franklin Pickaway Fairfield Hocking Mercer Auglaize Shelby Logan Union Hardin Allen Van Wert Paulding Putnam Hancock Wyandot Marion Delaware Morrow Seneca Sandusky Ottawa Lucas Fulton Williams Henry Wood Defiance Erie Huron Lorain Ashland Wayne Medina Cuyahoga Summit Knox Holmes Licking Coshocton Muskingum Tuscarawas Guernsey Perry Morgan Noble Belmont Harrison Carroll Columbiana Stark Portage Mahoning Trumbull Ashtabula Geauga Lake ABH CATCHMENT AREA Jefferson Belmont/Harrison/ Monroe Muskingum Area Allwell Washington Athens/Hocking/Vinton Gallia/Jackson/Meigs Adams/Lawrence/Scioto Perry Fairfield 18

19 OPIATE-RELATED ADMISSIONS FY13 FY14 FY FY16 1st & 2nd Qtrs FY Opiate Related Admissions Total Admissions 19

20 Ohio RPHs have utilized Integrated Dual Diagnosis Treatment (IDDT) in the state RPHs since 1999 (Dartmouth-New Hampshire Model) Changing patient characteristics made this less applicable to entirety of patient population More acute care: shorter LOS More patients with primary OUD and no SMD New approach: Forensic patients: IDDT Civil patients: SBIRT/ABIRT 20

21 Developed January 2013 Components: Assessment: Universal checking of PDMP (OARRS) Basic treatment to stabilize psychiatrically Basic treatment to manage withdrawal and stabilize medically, within the medical capabilities of the RPH Clonidine as preferred choice for withdrawal management More specific treatment, discharge planning and treatment linkage based on individual patient needs 21

22 March 2013: Noted several deaths post-discharge d/t suspected opioid overdose Implemented Project Dawn in RPHs: all patients with opioid use disorder and their families were provided education and offered a naloxone kit 2/3 of patients accepted a kit Helpful in gaining exposure and acceptance of naloxone among healthcare professionals and broader community 22

23 Trevino and Raia, 2015; 23

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25 Extended-Release Injectable Naltrexone Buprenorphine Methadone Frequency of Administration Route of Administration Restrictions on Prescribing or Dispensing Abuse and Diversion Potential Additional Requirements Outcomes Monthly Daily Daily Intramuscular injection in the gluteal muscle by healthcare professional. Any individual who is licensed to prescribe medicine (e.g., physician, physician assistant, nurse practitioner) may prescribe and order; administration by qualified staff. Oral tablet or film is dissolved under the tongue. Can be taken at a physician s office or at home. NEW FORM: IMPLANTABLE Only licensed physicians who are DEA registered and either work at an OTP or have obtained a waiver to prescribe buprenorphine may do so. No Yes Yes None; any pharmacy can fill the prescription. Improved social functioning; may reduce criminal activity more than other drugs; high dropout rate Physicians must complete limited special training to qualify for the DEA prescribing waiver. Any pharmacy can fill the prescription. Improved social functioning; good drug for client retention at adequate doses; suppresses illicit opiate use at adequate doses Oral (liquid) consumption usually witnessed at an OTP, until the patient receives take-home doses. Only licensed physicians who are DEA registered and who work at an OTP can order methadone for dispensing at the OTP. For opioid dependence treatment purposes, methadone can only be purchased by and dispensed at certified OTPs or hospitals Improved social functioning; best drug for client retention; suppresses illicit opiate use Source: Center for Substance Abuse Treatment 25

26 Medication With MAT (% Opioid Free) Without MAT (% Opioid Free) NNT Naltrexone ER 36 % 23 % 7.7 Buprenorphine % 6% Methadone 60 % 30 % 3.3 NOTES: COMPARATIVE CONCLUSIONS CANNOT BE DRAWN FROM THIS ALL MAT WAS PROVIDED ALONG WITH RELAPSE PREVENTION COUNSELING References: Krupitsky 2011, Mattick 2009, Fudala 2003, Weiss,

27 Decreased mortality associated with relapse Reduced cravings and preoccupation Reduced effects of slip (one time exposure) Treatment retention Decreased illicit opioid use Less needle sharing Decreased arrests Improved family stability More employment 27

28 Preferred MAT is long-acting naltrexone Occasionally, patients are induced with suboxone when outpatient follow-up can be confirmed Methadone is not initiated (per federal law) 28

29 It is permissible for a physician, or authorized hospital staff, to administer or dispense narcotic drugs in a hospital to maintain or detoxify a person as an incidental adjunct to medical or surgical treatment of conditions other than addiction [21 CFR (c)] Check dose with outpatient prescriber Do not provide as discharge medication Arrange same day appointment at discharge 29

30 Medication-assisted treatment Workforce development Immediate access Primary prevention Screening, Brief Intervention, and Referral to Treatment (SBIRT) Recovery supports, including peer Addressing secondary trauma amongst first responders 30

31 Despite our efforts, mortality rate hasn t fallen yet Inadequate uptake of evidence-based treatments Culture against MAT Reticence to accept harm reduction approaches Effective prevention approaches Bias against people suffering with substance use disorders (and they are suffering) and those who treat them Long term effects: Children: effect on development and future life trajectory Adults: long-term physical effects, social effects, longevity What is the new normal going to be? Future of Medicaid 31

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34 57 for every person in Ohio 34

35 Medication Naltrexone ER Buprenorphine Methadone # of Ohioans receiving 503 in OTPs* in other practice settings** total 38,224 in OBOTs*** 2,368 in OTPs* 40,592 total 7,929 (all in OTPs)* Any form of MAT Approximately 50,000 *Ohio MHAS OTP data **Data from Alkermes pharmaceuticals ***OARRS data 35

36 School year Total Students 16,510 17,793 53,771 59, ,418 Presentations Ambassadors ,575 Subscribers to bi-weekly tips: 61,119 36

37 We ve done this before: Ischemic heart disease AIDS We have good treatments and prevention already available just need to use them more broadly Community invested in addressing Could this de-stigmatize substance use disorders? Could we learn to monitor major changes in national practices to limit unintended consequences? Role of technology, applications of AI, etc. 37

38 Mark Hurst, M.D., Medical Director, OhioMHAS (614) Tracy Plouck, Director, OhioMHAS (614)

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