Opioid Use and Misuse: History, Trends, And The Oregon Opioid Initiative

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1 Opioid Use and Misuse: History, Trends, And The Oregon Opioid Initiative John W. McIlveen, Ph.D., LMHC, State Opioid Treatment Authority, Oregon Health Authority, Addictions and Mental Health Division Opioids in the United States: Motor Vehicles and Opioid Deaths: 2006 Opioids in the United States: Motor Vehicles and Opioid Deaths: 2010 Opioids in the United States: A Historical Perspective Opioid use widespread and common in the US at turn of 19 th /20 th century prescribed for a variety of aliments Peak usage late 1800 s, by 1910 around 1 in 400 Americans opioid dependent Majority female users (as many as ¾ths) 1914 Harrison Act to regulate commerce and the opioid trade Drastic changes in the way this population was treated Opiates prescribed only in the course of practice (addiction not seen as a disease condition and not included)

2 Opioids in the United States: A Historical Perspective 1950 s New York City heroin epidemic Drs. Marie Nyswander and the beginning of methadone treatment Nearly 100% relapse rates for abstinence based treatment for opioid addicts Hypothesis the opioid addicted brain lacks something opioid endogenous system Opioids in the United States: A Historical Perspective DATA 2000: Office based treatment of opioid dependence Act of Congress any schedule III, IV, or V controlled substance with FDA approval for treatment of opioid dependence could be prescribed by a qualified physician Buperenorphine Schedule III Expanding office based treatment options Opioids in the United States: Current Trends Prescription opioid sales, deaths and treatment: nonmedical use of prescription pain medications; 4.8% of those aged 18 25; 1.9 million prescription narcotic users/ diagnostic criteria for opioid abuse or dependence (second only to marijuana (4.3 million) 2.1 million people in the United States with substance use disorders related to prescription opioid pain relievers in 2012; estimated 467,000 addicted to heroin (SAMHSA, 2012) National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set,

3 First Use of Opioids: By Decade Age of First Heroin Usage: By Decade Cicero et al., 2014 Cicero et al., 2014 Opioids in the United States: Heroin Facts Publicly funded facilities in 2012, opioid admission second only to marijuana (TEDS, 2012) User population increasing more rapidly than any other drug of abuse, despite overall numbers being vastly lower than virtually all other illicit drugs; doubled between 2007 (161,000) and 2013 (289,000) (NSDUH, 2013) Cocaine users five times that of heroin users but double the amount of deaths associated with it s use (CDC, 2014) Wide variances in methods of reporting heroin realted deaths (Warner et al., 2013) Opioids in the United States: Data 2000

4 Opioids in the United States: Treatment Considerations in a Medicaid Population SUDs and Medicaid clients appx. 12% (SAMHSA, 2013) Opioid overdose rates much higher among Medicaid population (Kuehn, 2014) Approximately 4.4% of Medicaid clients receive SUD treatment any given year (SAMHSA, 2013) 1.4% of Medicaid programs budgets go towards SUD treatment (SAMHSA, 2013) Opioids in the United States: Infectious Disease ; 364% increase in HCV infection among young adults (<30) in Appalachia; coincides with similar rates of admission for opioid dependence (MMWR, 5/8/15) 2007 HCV surpasses HIV as cause of death (Ly et al., 2012) 2015 Indiana HIV outbreak; directly related to IV drug use Wide variance in rates of infection for IV drug users in different areas of the country; from appx. 65% to as low as 10%, strongly correlated with access to public health services (Fatseas et al., 2011) Goals Decrease drug overdose deaths, hospitalizations, emergency department visits, and misuse Increase use of medication assisted treatment for opioid use disorder Decrease health care costs 15 16

5 Oregon Opioid Initiative Oregon Opioid Initiative Partnership Align and coordinate Oregon Health Authority Programs: Medicaid funded care CDC funded injury epidemiology and prevention programs SAMHSA funded prevention and treatment CDC funded chronic disease self management Pain Commission Health Systems Interventions Targeted PDMP Registration and Use Removed methadone as a preferred drug from the state formulary Adoption of opioid management by Medicaid Coordinated Care Organizations (CCOs) as a Statewide Performance Improvement Project Implement opioid prescribing guidelines for practitioners Oregon Pain Guidance Emergency department guidelines Target the most frequent prescribers for PDMP enrollment 23% of prescribers write 81% of controlled substance prescriptions Targeted enrollment has the support of the Oregon Medical Association and the Oregon Hospital Association Expand medication assisted treatment, non opioid treatment reimbursement Establish and monitor metrics; use data to monitor progress 19 20

6 Oregon Pain Guidance Naloxone Rescue 467 naloxone rescues were reported in 2014 in Multnomah County Heroin deaths dropped 30% in Multnomah County since 2011 (unpublished data) Dr. Jim Shames, Jackson County Public Health Oregon Emergency Department Opioid Prescribing Guidelines Oregon Chapter of Emergency Department Physicians have developed guidelines Includes: single medical provider to provide all opioids for chronic pain, long acting or controlled release opioids should not be prescribed from the emergency department, encourages prescribers to check the PDMP Sharon Meieran, MD at ocep.org/ Community Interventions Establish pain guidance groups for health care provider community Implement coordinated community based specialized pain care Convene community action workgroups Increase naloxone rescue projects and distribution to at risk patients Implement public education 23 24

7 Oregon Legislative Policy Interventions Enhance the Prescription Drug Monitoring Program Emergency Department Information Exchange (EDIE) Identified data for research Automated notifications Real time data?? Naloxone statute amendments Oregon Statewide Policy Directions Enhance the Prescription Drug Monitoring Program Increase naloxone distribution and usage Increase the number of health systems screening for opioid use disorder and adopt prescribing guidelines Oregon Statewide Policy Directions Expand health insurance coverage for evidence based alternative pain management for chronic non cancer pain Ensure that health insurance covers full spectrum of services to treat opioid use disorder Increase the availability of medication assisted treatment for opioid use disorders Importance of Data Monitor impact of interventions using data Link PDMP data with health outcomes Establish data dashboards to rapidly disseminate data to stakeholders 27 28

8 Immediate Actions and Potential Impacts Increase registration and use of PDMP Reduced high dose opioid prescribing, problematic co prescribing of opioid and benzodiazepines, use of multiple prescribers for opioids, and reduce the incidence of opioid naive patients transitioning to chronic episodic and chronic opioid use Increase use of non opioid pain therapies Contact John W. McIlveen, Ph.D., LMHC State Opioid Treatment Authority Oregon Health Authority/Health Systems Division PH: Increase use of claims reviews to identify high risk prescribing 29 30