Vermont s Response to the Opioid Crisis Alumni Scientific Session Dr. Harry Chen Commissioner of Health (former) 2011-2017 May 12, 2017
The Problem Opioids are powerful and useful pain killers. Opioids are highly addictive. Opioid overdose and addiction is a growing public health problem. Prescribers play a role in the supply and use of opioids in the treatment of pain and addiction in our communities.
Rolling Stone Magazine 4/3/2014 http://www.rollingstone.com/culture/news/the-new-face-ofheroin-20140403
The distribution of morphine consumption in 2009 was highly disproportionate to the general population distribution around the world. SOURCE: International Narcotics Control Board. http://www.incb.org/incb/en/narcotic-drugs/availability/availability.html 5
SOURCE: International Narcotics Control Board. 6 http://www.incb.org/incb/en/narcotic-drugs/availability/availability.html
States with more opioid pain reliever sales tend to have more drug overdose deaths Death rate, 2011, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA s Automation of Reports and Consolidated Orders System 7
Doctors are the most common source of opioids for most frequent nonmedical users. SOURCE: Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of pastyear nonmedical use: United States, 2008-2011. JAMA Internal Medicine. 2014 8
The higher the morphine milligram equivalent, the higher the overdose death hazard. SOURCE: JAMA 2011;305:1315-1321 9
Patients receiving high doses of opioid pain relievers account for disproportionate share of overdoses. 100% multiple doctors, high doses 90% multiple doctors, one doctor, high dose 80% high doses 70% 60% 50% one doctor, lower dose 40% one doctor, high dose 30% 20% 10% 0% patients receiving opioid pain relievers one doctor, lower dose patients overdosing with opioid pain relievers SOURCE: CDC Grand Rounds: Prescription Drug Overdoses a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);10-13. 10
an epidemic of suicides and afflictions stemming from substance abuse: alcoholic liver disease and overdoses of heroin and prescription opioids.
All-cause mortality, ages 45 54 for US White non-hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE). Anne Case, and Angus Deaton PNAS 2015;112:15078-15083 2015 by National Academy of Sciences
Mortality by cause, white non-hispanics ages 45 54. Anne Case, and Angus Deaton PNAS 2015;112:15078-15083 2015 by National Academy of Sciences
Overall Opioid 2015 Death Rate by State Source: CDC Wonder as compiled by the Washington Post
Vermont is the Only Northeastern State without a Statistically Significant Increase in Drug Overdose 2014 to 2015 Source: CDC/NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs.
New England Drug Overdose Deaths 40 35 30 Connecticut Maine 25 Massachusetts 20 New Hampshire Rhode Island 15 Vermont 10 Deaths per 100,000 5 2010 2011 2012 2013 2014 2015 Source: CDC/NCHS, National Vital Statistics System, mortality data. Includes opioids and other drugs
Vermont Drug Poisoning Estimated Deaths by County (All Drug Poisoning Deaths) Source: Centers for Disease Control and Prevention, Drug Poisoning Mortality: United States, 2002-2014 Vermont s 2014 age adjusted rate of drug poisoning deaths is the same as the U.S. average at approximately 14.7 per 100,000 Vermonters. January 2016
Drug-Related Fatalities Involving Opioids Total number of accidental and undetermined manner drug-related fatalities involving an opioid (categories not mutually exclusive) Total opioid Rx opioid Heroin Fentanyl 76 69 61 61 41 47 50 45 38 37 34 34 32 20 25 29 9 9 5 18 0 5 6 12 2010 2011 2012 2013 2014 2015 Source: Vital Statistics System
Key Surveillance Needs Respond to emerging issues
Emergency Department Discharge Data Emergency Department Discharge Rate per 100,000 People for Opioid Overdose, by Type of Opioid and Year Vermont Residents at Vermont Hospitals 1.3 1.5 1.3 Other opioids Heroin 2.6 1.6 1.7 1.6 1.4 1.3 1.4 1.6 1.7 1.5 0.2 0.3 0.2 0.1 0.1 0.2 0.1 0.1 0.2 0.6 1.4 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Vermont Uniform Hospital Discharge Data Set
Nationally, over half of those who misused a prescription pain reliever got it from a friend or relative. Source: National Survey on Drug Use and Health, 2015 21
Non-medical use of prescription pain relievers in Vermont Percent of Vermont population reporting non-medical use of pain relievers in the past year by age in years. 12-17 18-25 26+ 25 20 15 13 13 14 15 13 14 13 13 12 8 9 10 7 7 7 6 6 6 7 8 6 5 5 4 0 3 3 3 3 3 3 3 4 3 3 2 Source: National Survey on Drug Use and Health, 2003-2014 22
Heroin use among high school students remains low 10 9 8 7 6 5 4 3 3 3 2 2 2 1 Percent of high school students reporting heroin use within their lifetime by year 0 2009 2011 2013 2015 Source: Youth Risk Behavior Survey, 2013 and 2015 23
Opioid Misuse Young Adult Survey* & College Health Survey Percent of young adults who report opioid misuse in the past year by data source 2014 2016 25 20 15 10 8 6 6 5 5 0 Young Adult Survey *Young Adult Survey conducted by the Pacific Institute for Research and Evaluation under a contract with VDH College Health Survey Source: Young Adult Survey and College Health Survey 24
In 2012, Vermont had a relatively low number prescriptions per person 25
Number of Prescriptions by Drug Type and Year Total Number of Controlled Substance Prescriptions by Drug Type and Year Opioids Sedatives Stimulants Adjusted Opioids 601,506 538,403 482,572 502,566 513,773 509,057 498,973 281,624 284,571 287,121 289,756 291,011 291,833 111,203 128,169 150,617 164,655 173,199 185,315 2010 2011 2012 2013 2014 2015 Note: The 2015 Annual Report reflects the first full year of VPMS data with tramadol reclassified from a Schedule V to a Schedule IV drug. Its inclusion in VPMS data due to this reclassification resulted in an increase of 82,992 opioid prescriptions being reported to VPMS 2015. Additionally, the White River Junction Veterans Affairs Medical Center began uploading to VPMS in March of 2015. It uploaded 19,541 opioid prescriptions in 2015. Had these two new data sources not been provided to VPMS in 2015, the number of opioid prescriptions would have decreased for the first time since 2010. (See the Adjusted Opioids trend line.) 26
Prescription histories of Individuals with opioid-related accidental fatalities (ORAF) In 2015, 68 of 75 ORAF individuals had controlled substance prescription histories Of the 68, 81% received high dose (>90 MME) analgesics in the period before their deaths ORAF s with an opioid prescription in the year prior to fatality received average of 261 days supply in that year. % of ORAF with > 90 MME Opioid Rx by Time Elapsed Before Death Vermont Department of Health Source: Vermont Prescription Monitoring System and Vital 27Statistics
For every 1 fatal opioid overdose in VT there are: people receiving at least one rx for analgesics 1,482 nonmedical rx pain reliever users 235 113 needle exchange members 64 EMS overdose calls 18 people receiving at least one MAT service for OUD community opioid reversals emergency department visits for opioids infants born exposed to opioids 5 3 2
Actions to Address Opioid Drug Abuse Education Tracking and Regulation/Enforcement Identification verification at Prescriber Monitoring pharmacies education Vermont Prescription Law enforcement training on Community Drug Monitoring System prescription drug misuse and education (VPMS) diversion Naloxone Unified Pain Management distribution Regulation Treatment Options Keeping medications safe at home Care Alliance for Opioid Addiction Proper Medication Disposal Proper medication disposal guidelines consistent with FDA standards Community take-back programs Most Dangerous Leftovers Campaign Regional Treatment Centers Outpatient and residential treatment at state-funded treatment providers Harm Reduction 29
Regulation MAT Rule Based on DATA 2000 Unified Pain Management Rule (Chronic) VPMS (prescription monitoring) Patient contract Urinalysis requirement Pill counts Referral for risk Acute Pain Rule
The Problem As many as four out of five heroin users begin by abusing prescription drugs Of those who abuse prescription opioids, seven out of 10 received these drugs through methods of diversion Opioids are overprescribed. They are prescribed: Too often At too high a dose For too long One in four become addicted. One in 550 die from their opioids Prescribers play a role in the supply and use of opioids in our and use of opioids in communities.
http://www.cdc.gov/drugoverdose/prescribing/resources.html
Patient-level surveys of opioid use after surgery Dartmouth Hitchcock researchers examined opioid prescribing patterns after general surgery outpatient procedures. Results: An average of only 28% of pills were used To satisfy 80% of patient needs, could reduce Wide variation in quantity provided for each operation prescription amounts by 43% 1: Hill M, McMahon M, Stucke R, & Barth R. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Annals of Surgery. 2016; doi: 10.1097/SLA.0000000000001993
Patient-level surveys of opioid use after surgery UVM study (Nov. 2016), after general and orthopedic surgery, same wide variation found even within a practice. Results: 7% did not receive an opioid Of the 93% who received an opioid 12% did not fill the prescription 30% that filled the prescription didn t use any The overall median proportion used = 26%
New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults Chad M. Brummett, MD1,2; Jennifer F. Waljee, MD, MPH, MS2,3; Jenna Goesling, PhD1; et al JAMA Surg. Published online April 12, 2017. doi:10.1001/jamasurg.2017.0504 Conclusions: In a cohort of previously opioid-naive patients, approximately 6% continued to use opioids more than 3 months after their surgery, and as such, prolonged opioid use is a common postsurgical complication. New persistent opioid use is not different among patients who underwent minor and major surgical procedures, thereby suggesting that prolonged opioid use is not entirely due to surgical pain.
Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use Michael L. Barnett, M.D., Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D. N Engl J Med 2017; 376:663-673February 16, 2017DOI: 10.1056/NEJMsa1610524 department, and rates of long-term opioid use were Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers.
Percent of people getting 50% pain relief (from acute postop pain) 1/NNT From Cochrane Reviews 62.5 40 37 37 28 21 Two 5 mg Percocet pills Ibuprofen 200mg Ibuprofen 400 mg Oxycodone 15 mg Acetaminophen 500 mg Ibu 200 + acet 500 Source: Don Teater MD http://www.ncbi.nlm.nih.gov/pubmed/19588335 http://www.ncbi.nlm.nih.gov/pubmed/18843665
Universal Precautions First consider non-opioid and nonpharmacologic treatments Upon first prescription prescribers must: discuss risks including safe storage and disposal provide a patient education sheet, and receive an informed consent for all first opioid prescriptions Co-prescribe naloxone for prescriptions over 90 MME or if also on benzodiazepines Check the prescription monitoring system for everyone s first prescription exceeding 10 pills or a replacement prescription
Opioid Prescribing for Acute Pain First prescription to opioid naïve patients: Consider non-opioid treatment Prescribe minimum needed for pain 350 MME (50 MME per day for 7 days) limit Ensure a safe transition of care to patients PCP Avoid long-acting opioids
Opioid Prescribing for Minors Teens who used opioids for legitimate reasons in high school had a 33% increased risk for future misuse compared to their peers. 1 Consult with pediatrician before prescribing in ED Opioids as last resort for minor injuries Limits the first prescription to a total of 72 MME (24 MME for 3 days) 1 Miech R, Johnston L, O Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015;136(5):e1169-e1177.
Opioid Prescribing for Chronic Pain Universal precautions apply Informed Consent, Controlled Substance Treatment Agreement to be repeated annually Requires pain management plans and ongoing assessments of opioid effectiveness Sets a trigger for revaluation at 90 MME Stable patients must be evaluated at least every 90 days Co-prescribe naloxone for prescriptions over 90 MME or if also on benzodiazepines
People seek treatment for opioid addiction much sooner after first use than with alcohol Number of admissions Alcohol Opiates Opioids Alcohol 700 Average Elapsed Time 8.2 +/- 7 years 24.8 +/- 12 years 600 500 400 300 200 100 0 Elapsed Time (Years) Between Age of First Use and Age at Treatment Admission for Daily Users of Opioid and Alcohol (2005-2011) Elapsed Time (Years) Source: Alcohol and Drug Abuse Treatment Programs, admissions 2005-2011
Effectiveness of Medication Assisted Treatment Several studies have clearly demonstrated MAT is effective across a number of behavioral dimensions compared to placebo or psychological treatment alone: Reduced opioid use (including IVDU) Increased engagement and retention in treatment Reduced morbidity and mortality Improved social functioning Reduced criminal activity Reduced transmission of infectious diseases 45 45
Hub and Spoke Model Results for Patients + An established physician-led medical home + A single MAT prescriber + A pharmacy home + Access to existing Community Health Teams + Access to Hub or Spoke nurses and clinicians + Linkages between Hubs and primary care Spoke providers in their areas
Vermont has one of the highest rates of treatment capacity Rate of Past Year Opioid Abuse or Dependence* and Rate of Medication Assisted Treatment Capacity with Methadone or Buprenorphine Source: NSDUH 2003-2012 Source: N-SSATS 2003-2012 *Opioid abuse or dependence includes prescription opioids and/or heroin Source: AJPH 2015; 105(8):e55-63 47
The number of people using heroin at treatment admission is increasing faster than for other opioids Number of people treated in Vermont by substance and Fiscal Year 7,000 Alcohol Marijuana/Hashish Heroin/Other Opioids All Others 6,000 5,000 4,000 3,000 2,000 1,000 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: Alcohol and Drug Abuse Treatment Programs
While more heroin users inject than prescription drug users, the percent has remained fairly stable Primary Heroin Primary Rx Opiates 80.5% 81.9% 77.2% 75.7% 76.7% 73.1% 72.6% 74.8% 74.6% 76.5% 76.1% 24.8% 21.6% 18.5% 20.7% 21.6% 21.0% 23.3% 24.9% 25.7% 22.2% 23.2% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent of individuals treated for primary diagnosis of opioid misuse who are injection drug users by type of opioid and year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Alcohol and Drug Abuse Treatment Programs
People Treated for Opioid Abuse or Dependence by Age and Fiscal Year Number of People Treated for Opioid Abuse by Age and Fiscal Year 3000 2,839 <18 18-24 25-34 35-44 45+ 2500 2,040 2000 1,702 1500 1,381 1,147 1,215 947 796 718 747 850 863 972 1000 812 691 509 500 750 678 725 572 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Alcohol and Drug Abuse Treatment Programs
IV Drug Use at Admission OP/IOP/Residential Treatment 35% 30% 30% 26% 25% 20% 20% 16% 15% 13% 13% 13% 11% 12% 12% 10% 5% Percent of People with IVDU for Primary, Secondary, or Tertiary Substance of Abuse by CY 0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Alcohol and Drug Abuse Treatment Programs 51
As the total number of clients in treatment increased, the number of people waiting for services remains flat Census Waiting 3500 3000 2500 2000 1500 1000 500 0 Jan-14 Feb-14 Mar-14 Number of People in Hubs and Waiting for Hub Services Over Time Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Source: Alcohol and Drug Abuse Treatment Programs 52
MAT Evaluation: Preliminary findings Using 2007-2013 Vermont Medicaid data, analysis shows: Longer Medication Assisted Treatment corresponds to Individuals with an opioid dependent diagnosis receiving MAT have lower medical care costs than those who have an opioid dependent diagnosis and are receiving non-mat substance abuse treatment lower non-treatment related medical care costs 53
Patient functioning at hub discharge Of those completing treatment or transferring to another level of care, 75% show overall improved functioning at discharge Those who leave treatment for other reasons, such as leaving against medical advice, incarceration, or are administratively discharged, only 34% have improved functioning 54
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The total number of needles dispensed almost hit 1 million Total number of syringes dispensed by year 999,459 932,266 841,136 763,321 633,000 485,095 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2010 2011 2012 2013 2014 2015 Source: Vermont Syringe Exchange Programs 56
Vermont Syringe Exchange Programs Provision of sterile syringes and other injection supplies Safe disposal of used syringes (removal of used syringes from the community) Safer sex supplies and education Overdose prevention education and resources Referrals for substance abuse treatment Provision of harm reduction options while injection drug users prepare for or wait for treatment HIV and hepatitis C testing and referrals for follow up medical care if needed Referrals for recommended vaccines 57
Administration of Naloxone 58
Naloxone Number of doses dispensed by client type, quarter and year New Returning 1408 1174 1046 938 815 566 600 589 951 469 333 680 746 700 622 426 436 51 184 264 Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 Number of reports of naloxone use in response to a perceived overdose incident 145 119 122 102 71 85 51 32 31 8 Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Apr-Jun 2015 Jul-Sep 2015 Oct-Dec 2015 Jan-Mar 2016 Apr-Jun 2016 Source: Naloxone Pilot Program 59
Improved treatment and screening have helped to identify more infants exposed to opioids Source: Vermont Uniform Hospital Discharge Data Set 60
Change in Crimes/100,000 in Vermont 2011-2014 0.0-10.0-11.1-20.0-30.0-29.1-32.7-32.2-32.1-36.7-35.5-40.0-50.0-60.0-47.0 Violent Property Murder Forcible Rape Robbery Aggravated Assault Burglary Larceny-Theft Vehicle Theft -53.9 Federal Bureau of Investigation Uniform Crime Report
In Summary Vermont is putting in place many of the prevention, intervention, treatment and recovery options that could help turn the tide on the opioid crisis. Vermont is doing better than much of the country in substance abuse treatment, harm reduction and data collection. While the problem continues to increase, there are small signs of hope: Large parts of the state do not have wait lists for treatment Deaths from prescription opioids appear to be flattening * Naloxone is getting into the hands of those who need it most Youth use is trending downward over time
Thank you Source: http://www.hazecam.net/camsite.aspx?site=burlington Harry Chen, M.D. harrylchen@gmail.com http://healthvermont.gov/