Wisconsin s Opioid Crisis Learning Objectives Understand the extent of the opioid epidemic nationally. Learn drug trends and current data in Wisconsin. Understand the signs and symptoms of opioid misuse and abuse. Understand medication-assisted treatment (MAT) and its application in Wisconsin. Epidemiology United States 1
Hydrocodone Usage in United States 99% Oxycodone Usage in United States 8% Opioids Grip in the U.S., 217 Source: SAMHSA 218 2
Source of Pain Relievers Obtained for Most Recent Misuse, 217 53.1% 36.6% Prescriptions Some Other Way Drug Dealer/Stranger Friend/Relative Source: SAMHSA, 218 4.6% 5.7% Misuse of Prescription Opioid Subtypes Source: SAMHSA, 218 Synthetic Opiate Deaths Continue to Surge 3
Heroin Use and Deaths Use Deaths Source: SAMHSA, 218 Heroin, Fentanyl, and Carfentanil How many access treatment? 4
Receipt of Opioid Use Disorder Treatment at Specialty Facilities or Doctor Offices Source: SAMHSA, 218 Epidemiology Wisconsin Surveillance: Data Sources and Systems Death certificates Hospital discharge and emergency department data Enhanced Prescription Drug Monitoring Program (epdmp) Medical examiner or coroner data Emergency department encounter data Wisconsin Ambulance Run Data System 5
Three Waves of Opioid Overdose Deaths Prescription opioids was the first wave of the rise in overdose deaths. Heroin was the second wave of the rise in opioid overdose deaths. Fentanyl is the third wave of the rise in opioid overdose deaths. Wave 1: 1999 (Prescription Opioids) Deaths per 1, population 9 8 7 6 5 4 3 2 1 Wisconsin Opioid Deaths, 1999 217 Fentanyl Heroin Natural/semi synthetic 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 216 217 Wave 2: 21 (Heroin) Deaths per 1, population 9 8 7 6 5 4 3 2 1 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 216 217 Wisconsin Opioid Deaths, 1999 217 Fentanyl Heroin Natural/semi synthetic 6
Wave 3: 214 (Fentanyl) Deaths per 1, population 9 8 7 6 5 4 3 2 1 Wisconsin Opioid Deaths, 1999 217 Fentanyl Heroin Natural/semisynthetic 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 216 217 Wave 1: 1999 (Prescription Opioids) Number of deaths 5 45 4 35 3 25 2 15 1 5 Wisconsin Opioid Deaths, 1999-217 Heroin Natural/semisynthetic Fentanyl Cocaine Benzodiazepine Wave 2: 21 (Heroin) Number of deaths 5 45 4 35 3 25 2 15 1 5 Wisconsin Opioid Deaths, 1999-217 Heroin Natural/semisynthetic Fentanyl Cocaine Benzodiazepine 7
Wave 3: 214 (Fentanyl) Number of deaths 5 45 4 35 3 25 2 15 1 5 Wisconsin Opioid Deaths, 1999-217 Heroin Natural/semisynthetic Fentanyl Cocaine Benzodiazepine Wisconsin Overdose Deaths Number of Deaths 5 45 4 35 3 25 2 15 1 5 Heroin Natural/semi-synthetic Fentanyl Wisconsin Overdose Death Rates, 217 25 Rate per 1, population 2 15 1 5 Male Female All Opioids Prescription Fentanyl Opioids Type of Opioid Heroin 8
Opioid Deaths Rate Per 1, Population, 217 Wisconsin Opioid Deaths 217 County Deaths Rate per 1, County Deaths Rate per 1, County Deaths Rate per 1, Ashland <5 - Iron <5 - Portage <5 - Barron <5 - Jackson 6 29. Price <5 - Bayfield. Jefferson 18 21.3 Racine 44 22.5 Brown 28 1.8 Juneau <5 - Richland <5 - Buffalo. Kenosha 45 26.8 Rock 37 23. Burnett. Kewaunee. Rusk <5 - Calumet <5 - La Crosse 19 16.1 Saint Croix <5 - Chippewa 6 9.4 Lafayette <5 - Sauk 8 12.7 Clark <5 - Langlade. Sawyer <5 - Columbia 1 17.5 Lincoln <5 - Shawano <5 - Crawford <5 - Manitowoc 9 11.1 Sheboygan 18 15.6 Dane 88 16.9 Marathon 13 9.6 Taylor. Dodge 14 15.7 Marinette <5 - Trempealeau. Door <5 - Marquette 6 39.2 Vernon <5 - Douglas <5 - Menominee <5 - Vilas <5 - Dunn <5 - Milwaukee 31 31.7 Walworth 13 12.7 Eau Claire 6 5.9 Monroe 5 1.9 Washburn. Florence <5 - Oconto. Washington 2 14.9 Fond du Lac 6 5.8 Oneida. Waukesha 62 15.6 Forest <5 - Outagamie 17 9.3 Waupaca <5 - Grant <5 - Ozaukee 1 11.4 Waushara <5 - Green. Pepin. Winnebago 22 13. Green Lake <5 - Pierce <5 - Wood <5 - Wisconsin Opioid Use Disorder Rate Rate per 1, population 4 35 3 25 2 15 1 5 n=19,775 n=5,828 252627282921211212213214215216217 Year 9
Wisconsin Opioid-Related Hospitalizations 5 Number of Hospitalizations 45 4 35 3 25 2 15 1 5 All opioids Prescription opioids (including fentanyl) Heroin 26 27 28 29 21 211 212 213 214 215 216 217 Note: Drug overdose death numbers may include more than one type of drug. Year Wisconsin Opioid-Related Hospitalizations Rate per 1, population 9 8 7 6 5 4 3 2 1 All opioids Prescription opioids (including synthetic) Heroin 26 27 28 29 21 211 212 213 214 215 216 217 Note: Drug overdose death numbers may include more than one type of drug. Year Opioid-Related Hospital Encounters Rate Per 1, Population, 217 1
Wisconsin Opioid Hospitalizations 217 Rate per Rate per Rate per County Hospitalizations 1, County Hospitalizations 1, County Hospitalizations 1, Adams 86 419. Iowa 75 315.6 Polk 1 227.3 Ashland 172 182.6 Iron 21 359.6 Portage 139 196.5 Barron 123 267. Jackson 99 478.8 Price 33 237.3 Bayfield 8 53.4 Jefferson 364 431.5 Racine 91 461.4 Brown 675 261.2 Juneau 11 411. Richland 79 443.6 Buffalo 4 296.2 Kenosha 882 525.7 Rock 985 613.5 Burnett 71 459.8 Kewaunee 29 14.8 Rusk 36 247. Calumet 35 68.8 La Cross 437 37.4 St. Croix 28 238.8 Chippewa 224 35.3 Lafayette 25 148.1 Sauk 342 544.9 Clark 67 192.5 Langlade 77 39.3 Sawyer 144 865.7 Columbia 31 527.8 Lincoln 78 273.8 Shawano 127 35.6 Crawford 36 216.7 Manitowoc 394 487.4 Sheboygan 396 343.6 Dane 1726 33.8 Marathon 28 26.5 Taylor 31 15.1 Dodge 351 392.9 Marinette 173 42.6 Trempealeau 85 288.5 Door 5 179.2 Marquette 74 483.1 Vernon 69 227.3 Douglas 217 491.7 Menominee 57 1311.6 Vilas 111 514. Dunn 113 253.3 Milwaukee 8746 92.3 Walworth 47 396.2 Eau Claire 425 416.5 Monroe 156 341. Washburn 73 46.7 Florence 12 268.9 Oconto 83 218.7 Washington 522 389.2 Fond du Lac 367 356.9 Oneida 144 4. Waukesha 1825 459.9 Forest 66 716.5 Outagamie 422 23.6 Waupaca 2 383.9 Grant 117 221.3 Ozaukee 31 352.4 Waushara 71 291.1 Green 136 367.9 Pepin 11 149. Winnebago 468 276.4 Green Lake 52 273.7 Pierce 137 332. Wood 295 396.4 Opioid Overdoses Rate per 1, Population Hospital Discharge Data, 217 Non-Fatal Opioid Overdoses 217 County Non-fatal Opioid Overdoses Rate per 1, County Non-fatal Rate Opioid per Overdoses 1, County Non-fatal Rate Opioid per Overdoses 1, Adams 2 97.4 Iowa 22 92.6 Polk 12 27.3 Ashland 18 113.3 Iron <5 - Portage 2 28.3 Barron 19 41.2 Jackson 36 174.1 Price <5 - Bayfield 1 66.3 Jefferson 6 71.1 Racine 156 79.9 Brown 11 42.6 Juneau 25 93.4 Richland 11 61.8 Buffalo <5 - Kenosha 133 79.3 Rock 235 146.4 Burnett 1 64.8 Kewaunee <5 - Rusk 7 48. Calumet <5 - La Crosse 81 68.7 Saint Croix 35 4.2 Chippewa 37 57.9 Lafayette 6 35.5 Sauk 52 82.9 Clark 1 28.7 Langlade 16 81.1 Sawyer 16 96.2 Columbia 81 142. Lincoln 14 49.1 Shawano 16 38.5 Crawford 7 42.1 Manitowoc 57 7.5 Sheboygan 67 58.1 Dane 478 91.6 Marathon 52 38.3 Taylor <5 - Dodge 81 9.7 Marinette 28 68.1 Trempealeau 16 54.3 Door 12 43. Marquette 13 84.9 Vernon 11 36.2 Douglas 43 97.4 Menominee 5 115. Vilas 27 125. Dunn 18 4.3 Milwaukee 151 157.9 Walworth 74 72. Eau Claire 71 69.6 Monroe 33 72.1 Washburn 11 69.4 Florence <5 - Oconto 24 63.2 Washington 85 63.4 Fond du Lac 73 71. Oneida 13 36.1 Waukesha 319 8.4 Forest 1 18.6 Outagamie 64 35. Waupaca 29 55.7 Grant 26 49.2 Ozaukee 41 46.6 Waushara 16 65.6 Green 27 73. Pepin <5 - Winnebago 69 4.8 Green Lake 11 57.9 Pierce 13 31.5 Wood 44 59.1 11
Opioid Prescriptions Filled Controlled substance : Stimulants Other Opioids Benzodiazepines Number of prescriptions filled 6,, 5,, 4,, 3,, 2,, 1,, Source: Wisconsin Prescription Drug Monitoring Program 214 215 216 217 Year WI Pharmacy Purchases of Hydrocodone 211-217 12,, 1,, 8,, 6,, 4,, 2,, 118,53,21 112,742,18 11,312,77 15,235,97 94,65,93 82,866,264 53,431,85 211 212 213 214 215 216 217 Source: ARCOS DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit DOSAGE UNITS PURCHASED Date Prepared: 2/12/218 County Pharmacy Purchases of Hydrocodone, 216 U.S. Average = 87,261 dosage units DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Source: ARCOS Date Prepared: 2/12/218 12
County Pharmacy Purchases of Hydrocodone, 217 U.S. Average = 6,488 dosage units DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Source: ARCOS Date Prepared: 2/12/218 WI Pharmacy Purchases of Oxycodone 211-217 12,, 1,, 8,, 6,, 4,, 2,, 98,678,937 12,91,745 97,74,17 99,921,14 11,451,71 94,27,8 6,44,5 211 212 213 214 215 216 217 Source: ARCOS DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit DOSAGE UNITS PURCHASED Date Prepared: 2/12/2118 County Pharmacy Purchases of Oxycodone, 216 U.S. Average = 69,616 dosage units DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Source: ARCOS Date Prepared: 2/12/218 13
County Pharmacy Purchases of Oxycodone, 217 U.S. Average = 49,416 dosage units DEA, Office of Diversion Control, Pharmaceutical Investigations Section, Targeting and Analysis Unit Source: ARCOS Date Prepared: 2/12/218 Neonatal Abstinence Syndrome (NAS) Problems that occur in a newborn exposed to addictive illegal or prescription drugs while in the womb Symptoms High-pitched cry Jitteriness Tremors Generalized convulsions NAS Trend in Wisconsin Rate per 1, live births 9 8 7 6 5 4 3 2 1 26 27 28 29 21 211 212 213 214 215 216 217 Year of NAS Hospitalization Change in NAS definition 542 cases 14
NAS Trend in Wisconsin Rate per 1, live births 7. 6. 5. 4. 3. 2. 1.. 6.5 5.9 4.7 3.3 2.8 NAS rate 2. 2. 26 27 28 29 21 211 212 Year of NAS hospitalization NAS Trend in Wisconsin Rate per 1, live births 1 9 8 7 6 5 4 3 2 1 8.5 8. 8.4 8. 8.1 (563) (54) (566) (533) (542) NAS rate & (count) 213 214 215 216 217 Year of NAS hospitalization Health Risks 15
Hepatitis C (HCV) The number of acute HCV detections has increased substantially (from 3 in 29 to 16 in 216). In 216, the median age of acute HCV cases was 3 years-old and 5 percent were male. Hepatitis C (HCV) Most common reported risk factor was injection drug use As many individuals are unaware of HCV, the estimate is that 9, people in Wisconsin have an HCV infection. Department of Health Services has been notified of approximately 42,. Injection drug user grants Reported Acute HCV Cases, Wisconsin 12 Number 1 8 6 4 Acute HCV cases Ever injected drugs to get high 2 26 27 28 29 21 211 212 213 214 215 216 Year of positive HCV test 16
Heroin Overdose Deaths and HCV Infection Young People, Wisconsin, 26-216 12 1 8 Hepatitis C infections among Number 6 4 2 Heroin overdose deaths 26 27 28 29 21 211 212 213 214 215 216 HCV Infection Among Young Adults 28 216 (n=21) (n=818) Injection Drug Use-Infective Endocarditis It is an infection of either the heart s inner lining or the heart valves. It can be triggered by injection drug use, which can introduce bacteria into the blood stream. Young adults (ages 15 to 34) accounted for 28 percent of all cases in 2. This proportion grew to 42 percent in 213. 17
Injection Drug Use-Infective Endocarditis A research team found that injection drug use-related infective endocarditis grew from an estimated 3,578 cases in 2 to 8,53 cases in 213, despite a downturn in hospitalizations in 28. Other Health related issues HIV Sexually transmitted infections (STIs) Septic arthritis (infection of joints due to IV drug use) Osteomyelitis (infection and inflammation of the bone) Tuberculosis Thrombophlebitis (infection of the vein wall) Naloxone Naloxone is a medication used to counter the effects of an opioid overdose. Naloxone may be injected in the muscle, vein, under the skin, or sprayed into the nose. It is a temporary drug that wears off in 2 to 9 minutes. 18
Wisconsin Statewide Standing Order Allows pharmacists to dispense naloxone without a prescription Must follow DHS policy and procedure Signs of Opiate Abuse Behavioral/Physical Pill bottles Shoplifting/stealing Loss of appetite/weight 19
Behavioral/Physical Doctor shopping Itchy arms/neck/legs Wearing long sleeves Constricted/pinpoint pupils Anxiety Behavioral/Physical Sudden change in routine, mood Isolation Nodding off Sudden change in hygiene Blackened fingers/smudges Environmental Missing vent screws Burned carpet Torn corners of plastic baggies Burnt foil/spoons/tea candle tins 2
Environmental Pen parts/straws Crushed pills/white powder Torn Q-tip buds, cut cigarette filters Plastic bottle caps Environmental Folded receipts, lottery tickets Sunglasses case Blood spots in sink/bedding/clothes Medication-Assisted Treatment 21
Medication-Assisted Treatment Provides comprehensive services Medication Counseling Case management Recovery supports Medication-Assisted Treatment Uses many paths to recovery Medical intervention Professional treatment Mutual support groups Peer supports Family supports Faith supports Medication-Assisted Treatment Develops diversion practices and policies Develops recovery-oriented systems of care (ROSC) 22
Medication-Assisted Treatment Food and Drug Administration approved medications Buprenorphine products (Suboxone and Probuphine) Naltrexone (Vivitrol) Methadone Buprenorphine Products Schedule III narcotic medication Reduces cravings and withdrawal symptoms Available at opioid treatment programs (OTPs) and from approved practitioners (previously DATA waived physicians) Nurse practitioners and physician assistants now can prescribe after completing required training Probuphine Implant Requires office-based sterile procedure Contains 8 mg of buprenorphine Administered directly to patients Continuous delivery over six months Removed after six months New implant can be inserted in other arm 23
Sublocade First once-monthly injectable buprenorphine formulation for the treatment of moderate to severe opioid use disorder Sublocade Indicated for patients who have initiated treatment with a transmucosal buprenorphine-containing product followed by a dose adjustment period for a minimum of seven days Recommended dose is 3 mg monthly for the first two months followed by a maintenance dose of 1 mg monthly Monthly cost of $1,58 Buprenorphine Waiver Waiver now approved up to 275 patients Practitioners eligible to obtain the waiver if they have additional credentialing in addiction medicine or addiction psychiatry Physicians required to complete a SAMHSA reporting form each year 24
Approved practitioners in Wisconsin (November 217) Published with a limit of 3: 188 Published with a limit of 1: 86 Published with a limit of 275: 37 Not published with a limit of 3: 258 Not published with a limit of 1: 43 Not published with a limit of 275: 9 Approved practitioners in Wisconsin (November 217) Total with a limit of 3: 446 Total with a limit of 1: 129 Total with a limit of 275: 46 Naltrexone Vivitrol is a prescription injectable medication. It is administered once a month to prevent relapse to opioid dependence after detox. Patient must stop all opiates 7-1 days prior to injection. 25
Methadone Schedule II pharmaceutical opioid similar to oxycodone or morphine Binds to mu opiate receptor and proteins in various tissues Suppresses withdrawal symptoms and opioid cravings, also used for pain relief When properly prescribed does NOT produce a euphoric or tranquilizing effect Opioid Treatment Programs (OTPs) 2 centers in Wisconsin Can provide all three forms of FDA approved medication Addresses and phone numbers at www.dhs.wisconsin.gov/opioids Patients Served at Wisconsin OTPs 12 1 8 6 4 2 764 7721 86 816 1,626 213 214 215 216 217 26
Federal Grants Division of Care and Treatment Services Substance Abuse and Mental Health Services Administration Strategic Prevention Framework Partnerships for Success 215 (SPF PFS 15) Prescription Drug/Opioid Overdose-Related Deaths Prevention Project (WI PDO) Strategic Prevention Framework for Prescription Drugs (SPF Rx) State Targeted Response (STR) State Opioid Response (SOR) SPF PFS 15 $8.2 million over 5 years (Sept. 215-Sept. 22) Focus: Prescription drug misuse and abuse among those 12-25 years-old 27
SPF PFS 15 Location/counties: Ashland Columbia Dane Douglas Eau Claire Florence Forest Vilas Oneida Kenosha Marinette Menominee Milwaukee Rock SPF PFS 15 Strategies Promotion of Dose of Reality campaign Promotion of medication security, collection, and disposal Education for prescribers Support for Drug Recognition Expert training for law enforcement Support drug identification training for educators SPF PFS 15 Alliance for Wisconsin Youth regional prevention centers are funding one coalition to implement these strategies in each of the 14 high need counties. The coalitions began their implementation efforts on October 1, 217. 28
WI PDO $5 million over 5 years (Sept. 216-Aug. 221) Focus: Overdose death prevention, naloxone distribution Location/counties: Kenosha (Public Health Department), Sauk (Public Health Department), Waukesha (Health and Human Services Department) WI PDO Trained staff on best practices Hosted trainings for first responders and family members on how to use naloxone, more than 4,2 individuals trained with more than 7 opioid overdoses reversed as a result of trainings SPF Rx $1.8 million over 5 years (Sept. 216-Aug. 221) Focus: Raise awareness of the risks of opioids, promote safe prescribing practices, establish system to track misuse trends Location/counties: Dodge and Sauk 29
SPF Rx Conducted needs assessment to select targeted counties Established local substance abuse prevention coalitions and provided support to build programming. Collaborated with the State Epidemiological Outcomes Workgroup to support development of an opioid-related data portal for use by stakeholders statewide. STR $15.2 million over 2 years (May 217-April 219) Focus: Advance prevention strategies, expand access to treatment and recovery supports, increase retention in treatment services, and reduce opioid-related deaths Location/counties: All regions of Wisconsin STR Awarded grants to Alliance for Wisconsin Youth coalitions to complete prevention projects. Established ED2Recovery through partnership with Wisconsin Voices for Recovery to help overdose survivors avoid another overdose and encourage them to stay engaged in treatment. 3
STR Awarded a grant to the Marshfield Clinic to equip their AmeriCorps workers with recovery coach training. Contracted with the UW-Madison School of Medicine to develop a toolkit for hospitals to prevent repeat overdoses. STR Awarded grants to fund unmet treatment needs. Awarded grants to two groups to provide medication-assisted treatment in Adams, Dodge, Juneau, Manitowoc, and Marquette counties, the programs began serving people in the spring of 218. STR Awarded grants to Forest County Potawatomi, Milwaukee County, Southwestern Wisconsin Community Action Program, and Tellurian to offer medication-assisted treatment in their areas. 31
STR Hosted Wisconsin s Opioid Crisis: A Trauma-Informed Response in March 218, more than 2 professionals attended. Hosted Opioid Forum in April 218, more than 5 professionals from a variety of fields attended. SOR $23.8 million over 2 years (Oct. 218-Sept. 22) Focus: Increase access to medicationassisted treatment, reduce unmet treatment need, reduce opioid-related deaths Location/counties: All regions of Wisconsin SOR The DHS workplan for this grant continues funding for the initiatives developed under STR. 32
Federal Grant Success Story Medication-Assisted Treatment Prescription Drug and Opioid Addiction (MAT-PDOA) $3 million over three years (Aug. 215-July 218) Expanded medication-assisted treatment options in Sauk and Columbia counties Federal Grant Success Story: MAT-PDOA Recruited local physicians and medical clinics to work with the project Admitted 253 individuals for treatment to date, exceeding grant goals Project ECHO Training for treatment providers in pharmacotherapy and behavioral interventions for opioid misuse and addiction Free video conferences held third Friday of every month (12:3-1:3 p.m.) Case-based learning from specialists in addiction medicine 33
Addiction Medicine Consultation Line Support for treatment providers managing patients with addictions Free service Operated by UW-Madison School of Medicine and Public Health and UW Health Funded by grant from DHS 8-472-111 Wisconsin Addiction Recovery Helpline 24/7 free service to launch October 22, 218 Provided by 211 Wisconsin under a grant from DHS Referrals to treatment and recovery services Help navigating insurance coverage questions Federal Grants Division of Public Health 34
Centers for Disease Control and Prevention Prescription Drug Overdose Prevention for States (PDO PfS) Enhanced State Opioid Overdose Surveillance (ESOOS) For More Information Elizabeth Collier State Opioid Treatment Authority elizabeth.collier@dhs.wisconsin.gov 68-267-777 Dennis Radloff MAT Expansion Coordinator dennis.radloff@dhs.wisconsin.gov 68-267-1427 www.dhs.wisconsin.gov/opioids 35