Changing Course: statewide efforts to combat the opioid epidemic in California Kelly Pfeifer, MD kpfeifer@chcf.org April 26, 2018 State of Reform conference
STAT Special Report: 52 weeks, 52 faces Obituaries narrate lives lost to the opioid epidemic More people die from alcohol and tobacco use, but neither is likely to kill you tonight. Opioid overdose robs decades from young lives. California Health Care Foundation www.chcf.org 2
Four Strategies to Lower Death Rates 1. PREVENT 2. MANAGE Prevent new starts on long-term opioid use. Manage chronic pain safely, focusing on highest risk: high dose, opioids + sedatives. 3. TREAT 4. STOP California Health Care Foundation Treat addiction effectively: medications for addiction treatment (MAT). Stop deaths with harm reduction: naloxone needle exchanges supervised injection sites www.chcf.org 3
How are we doing? California Health Care Foundation www.chcf.org 4
www.cdph.ca.gov/opioiddashboard California Health Care Foundation www.chcf.org 5
PREVENT: MME = morphine mg equivalents Total opioids prescribed Rationale: Risk of prolonged use: ^ by 1% per day > 3d Source: California Opioid Overdose Surveillance Dashboard: https://cdph.ca.gov/opioiddashboard Day 5 Day 30 Source: Pain Medicine, Volume 17, Issue 1, 1 January 2016, https://academic.oup.com/painmedicine/article/17/1/85/1752837
MANAGE: People on high-dose opioids (MME = morphine mg equivalents) MME = morphine mg equivalents Rationale: Fatal ODs: 9x with high-dose 10x with opioids+benzos Source: California Opioid Overdose Surveillance Dashboard: https://cdph.ca.gov/opioiddashboard 9x death rate >120 MME 10x death rate when 10x benzos death added rate to opioids with benzos Source: Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort Study of the Impact of High-dose Opioid Analgesics on Overdose Mortality. Pain Med 2016; 17:85-98
TREAT: Total buprenorphine prescriptions (MME = morphine mg equivalents) Rationale: Source: California Opioid Overdose Surveillance Dashboard (rates per 100k): https://cdph.ca.gov/opioiddashboard Maintenance drops OD deaths Maintenance Detox 3x death rate after methadone detox 2x death rate after buprenorphine detox Maintenance Detox Methadone Buprenorphine Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies, BMJ 2017; 357;j1550
STOP DEATHS: Alarming Fentanyl Trends California Health Care Foundation Source: California Opioid Overdose Surveillance Dashboard: https://cdph.ca.gov/opioiddashboard www.chcf.org 9
We have a long way to go. California Health Care Foundation www.chcf.org 10
Treatment needs to be easier to access than street drugs. Brain in a tempest: Addiction means day-to-day survival MAT stabilizes brain chemistry: Ability to focus on recovery Treatment success at 12 months: Treatment with medications* Methadone: 74-80% Buprenorphine (Suboxone): 60-90% Naltrexone (Vivitrol**): 10-31%** Treatment without medications: 6% *Based on meta-analyses of research studies; rates of success lower in real-world settings **Most Vivitrol studies done for 3-6 months; 12-month registry study only had % discontinued due to meeting goals Source: California Health Care Foundation, Why Health Plans Should go to the MAT in the Fight Against Opioid Addiction 10 California Health Care Foundation www.chcf.org 11
How Much MAT Do You Need? Snapshots by county available at www.urban.org California Health Care Foundation www.chcf.org 12
California Opioid Safety Network Local leaders coming together to fight the epidemic, connected across the state Leaders: medical societies, county leaders, public health, hospitals, and others. Participants: Bringing together medical providers, pharmacies, law enforcement and corrections, advocates, consumers and families, addiction treatment, health plans, and others. Priorities: Opioid over-prescribing Access to addiction treatment Naloxone and harm reduction California Health Care Foundation www.chcf.org 13
California s Coordinated Campaigns Addiction treatment expansion programs California Health Care Foundation www.chcf.org Statewide Opioid Safety (SOS) Workgroup 14
What Can We Learn from Another Epidemic? US AIDS Deaths, 1981-2007 Effective medications. Massive effort to increase access. Anti-stigma campaign. --- AIDS deaths Source: Centers for Disease Control, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention California Health Care Foundation www.chcf.org 15
The French Experience: 80% Drop in Deaths Heroin OD deaths Buprenorphine prescriptions Methadone treatment California Health Care Foundation www.chcf.org 16
Every Door Is the Right Door Homeless Services Smart Care CA SUD treatment system Treating Addiction In Primary Care MAT-ED Pharmacies Project SHOUT California Health Care Foundation Jails and Prisons Rhode Island: access to Tx for all 61% drop in post-incarceration OD deaths with jail MAT www.chcf.org 17
Questions California Health Care Foundation Kelly Pfeifer, MD kpfeifer@chcf.org www.chcf.org 18
Narcotic Safety Initiative A health plan response to the opioid epidemic Salina Wong, PharmD Director Clinical Pharmacy Programs Blue Shield of California April 26, 2018 State of Reform conference
Blue Shield of California s Goal Three-year goal to decrease opioid use by 50% among Blue Shield members with non-cancer pain by the end of 2018 Blue Shield of California 20
people on chronically high doses of opioids prevent progression to chronic use for members newly starting opioids prescriptions and refills for members newly starting opioid through evidence-based interventions Prudent prescribing and proactive management Access to programs to manage pain, addiction, and substance abuse Diligence on fraud, waste, and abuse Enhanced coverage policies and formulary management Blue Shield of California 21
2014 2015 2016 2017 Blue Shield of CA Board of Directors review and approval Restrict extendedrelease opioids Narcotic case management Provider awareness Limit high dose prescribing Prevent stockpiling Prevent extended use for acute pain Pharmacomedical analyses Enhanced opioid reporting to prescribers Public awareness Senate HELP Committee briefing CHCF case study Safe Med LA Medication Assisted Therapy (MAT) Limit overprescribing for acute pain, cough, cold Prescriber education/ training Chronic pain management program Blue Shield of California 22
Collaborating with Providers 1. Education and training 2. Clinical rounds with multi-disciplinary team and specialty expertise 3. Patient education: 6-8 week class 4. In-house pain & opioid use disorder (OUD) specialists for easy/fast referral 5. Policies/procedures, pain contracts, urine testing 6. Shared decision-making, risk assessments 7. Pain assessment protocols deployed by pharmacist providers during patient appointments, shared with physician, including medication recommendations Blue Shield of California 23
Our progress 18% 42% Blue Shield of California 24
Challenges and Opportunities 1. Awareness and action by all prescriber types & pharmacists, in all settings 2. Differentiation of pain specialists based on opioid prescribing practices 3. Identifying evidence-based treatment programs 4. Access to behavioral health services 5. Expanding primary care management of opioid use disorder 6. Insurance fraud Blue Shield of California 25
Making a difference Covered CA member Helped by narcotic case management 56 yr. old female with lupus and chronic pain syndrome Out-of-network prescriber 550 mg morphine equivalent dose (MED): meperidine 300 mg/day hydromorphone 4mg 10x per day fentanyl up to150mcg every 48 hrs Now member is seeing an in-network provider and only taking hydromorphone 16 mg/day. MED = 64 88% reduction in daily opioid dose! Blue Shield Prescriber reports working Blue Shield provider called specifically to let us know about a 64 yr. old member on a holy trinity combination with opioid Rx, identified in the Blue Shield report mailed to his office. Prescriber stopped two of the medications (benzodiazepine and muscle relaxant). He had been meaning to do this for some time, but the report provided good motivation to discontinue these medications. Blue Shield of California 26
Why it matters Referred to substance abuse treatment Medicare PDP member with thoracic spinal pain with total opioid doses up to 800 MED. Left Blue Shield Nov. 2015, but returned 2016. Now managed by a new provider and tapered down to 50 MED and in substance abuse treatment on buprenorphine. >90% reduction in daily opioid dose! Accountable Care (ACO) partnership driving change Member with an ACO primary care physician identified using compounded hydromorphone injectable plus many other opioid Rx s written by an out-of-network provider. Blue Shield pharmacist + ACO pharmacist worked together to discontinue compounded hydromorphone and taper utilization of other opioids, dropping MED by 50%. Repatriated member back into ACO to manage & coordinate care. Blue Shield of California 27
OPIOIDS: THE SYSTEM GENERATED AMERICAN EPIDEMIC Health and Human Services Agency Dr. Nicole Esposito - Behavioral Health Services - Assistant Medical Director 28
SAN DIEGO COUNTY MEDICAL EXAMINER REPORT (2000 2016) UNINTENTIONAL DEATHS DUE TO DRUG/MEDICATION TYPE 29
PAIN MANAGEMENT PRACTICES 30
RESPONSE FROM HEALTHCARE PROVIDERS Improved Quality of Care: Better pain management practices Better identification of addiction Gaps Still Remained: Poor access to integrated approaches to pain management Poor access to SUD treatment
DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM Case Management Recovery Residences Withdrawal Management Medication Assisted Treatment Network Adequacy
LINKING CARE: DMC-ODS JUSTICE SYSTEM PRIMARY CARE MENTAL HEALTH SYSTEMS Recovery Residence Withdrawal Mgmt. ACUTE CARE HOSPITALS EMERGENCY DEPARTMENTS Treatment Programs SOCIAL SERVICES
MOVING FORWARD Build system capacity Information sharing Provider to Provide communication 34
DMC-ODS QUESTIONS/COMMENTS? 35
Questions & Discussion Kelly Pfeifer, MD kpfeifer@chcf.org Nicole Esposito, MD nicole.esposito@sdcounty.ca.gov Salina Wong, PharmD salina.wong@blueshieldca.com California Health Care Foundation www.chcf.org 36