Arizona State Office of Rural Health Webinar Series

Mute your phone &/or computer microphone Time is reserved at the end for Q&A Please fill out the post-webinar survey Webinar is being recorded Recording will be posted on the SWTRC www.southwesttrc.org/ and the AzCRH www.crh.arizona.edu/

Arizona State Office of Rural Health Monthly Webinar Series Focused on providing technical assistance to rural stakeholders to disseminate research findings, policy updates, best-practices and other rural health issues to statewide rural partners and stakeholders throughout the state.

Arizona s Opioid Epidemic: Understanding the Problem and Finding Solutions 1. Understand the ontology of the rising rates of opioid use nationally and in Arizona 2. Understand the deleterious consequences occurring as a result of the rising trends in opioid use 3. Identify solutions that individuals can take across healthcare, substance abuse treatment and the general community

Today s presenter: Shana Malone Clinical Initiatives Project Manager AHCCCS - Office of the Director Shana Malone is a Clinical Initiatives Project Manager in the Office of the Director at the Arizona Health Care Cost Containment System. Shana oversees the agency initiative to reduce the effects of the opioid epidemic in Arizona. Shana has an M.S. in Human Development with a clinical specialty in family systems therapy and completed her doctoral coursework in the School of Social and Family Dynamics at Arizona State University. Her academic work focused on computational social science, social and emotional development and dynamical systems applications. Prior to coming to AHCCCS, Shana was the Director of the Statistical Analysis Center at the Arizona Criminal Justice Commission where she developed the original pilot model for the Arizona Prescription Drug Misuse and Abuse Initiative. Shana has worked on several local and national multi-systemic prevention and evaluation health outcome projects, and she has experience as a therapist in Arizona. 2015 UA Board of Regents

Arizona s Opioid Epidemic Understanding the Problem and Finding Solutions

The National Opioid Influx A 4 fold increase in the quantity of Rx Opioids sold in the U.S. The U.S. makes up 4.6% of the world s population, but consumes 80% of its Rx opioids 91 opioid deaths every day!

Percent (%) of Youth Reporting Misuse/Use Past 30 Day Rx Drug Misuse Among Arizona Youth (AYS) 12% 10.4% 10% 8% 7.9% 6.3% 6.6% 6% 4% 2% 0% 0.8% 0.4% 0.3% 0.3% 2010 2012 2014 2016 *Y-axis altered for visual purposes; accurate representation is out of 100% AnyRx Heroin 8

Percent (%) Youth Reporting Misuse Past 30 Day Youth Rx Drug Misusers Reporting Cocktailing (AYS, 2016) 100 90 80 70 60 50 40 30 20 10 What puts our kids at elevated risk even though we only have 6.6% misusing Rx Drugs? 33.4 31.6 0 Alcohol+Rx Opioids *Y-axis altered for visual purposes; accurate representation is out of 100% Rx Opioids+Rx Sedatives 9

Percent (%) Reporting Misuse Arizona Adult Rx Drug Misuse (BRFSS, 2014) 100% 90% 80% 70% 60% 50% 40% 30% 56.8% 20% 10% 19.6% 32.5% 0% Past 30 Days Past 12 Months but Not Past 30 Days Lifetime but Not Past 12 Months 10

Emerging Heroin Trends 11

Fentanyl 12

What the Opioid Epidemic is Costing Arizona 13

Event Rate Per 100,000 Population Arizona Opioid-Related ED Encounters and Hospital Admissions 350 300 114.5% Increase 250 91.6% Increase 200 150 EMERGENCY ENCOUNTERS HOSPITAL ADMISSIONS 100 50 0 2010 2011 2012 2013 2014 2015 14

9 8 7 Neonatal Abstinence and Newborn Drug Exposure Rates per 1,000 Births AHCCCS represented 51% of Arizona hospital births between 2008 and 2014, but was the payer for 79% of the NAS cases 218% Increase 6 245% Increase 5 4 3 2 1 0 2008 2009 2010 2011 2012 2013 2014 Neonatal Abstinence Syndrome (779.5) Narcotic Exposure (760.72) Cocaine Exposure (760.75) Fetal Alcohol Syndrome (760.71) Hallucinogen Exposure (760.73) 15

Number of drug poisoning deaths Number of Drug Overdose Deaths Involving Opioids, Arizona 2005-2015 (ADHS) 500 450 400 350 44.2% Increase Opioid pain relievers* (T40.2-T40.4) 300 250 693.3% Increase Heroin (T40.1) 200 150 100 50 *includes methadone 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year

Finding a Solution

3 Groups to Target 1. Opioid-Naïve Individuals 2. The Chemically Dependent 3. Diverters

3 Strategies to Implement 1. Harm Reduction 2. Prescribing/Dispensing Practices and Patient Ed 3. Access to MAT

Why Naloxone? The obvious it saves lives! Reversals between Jan-March 2017 Creates awareness Community distribution Someone understands and cares Access to additional services and resources Pipeline to treatment referral 20

Strategic Plan STRATEGY #1: Enhance Harm Reduction Strategies to Prevent Overdose o GOAL #1: Provide education and training on Naloxone to prescribers, pharmacists and AHCCCS members o GOAL #2: Increase member access to Naloxone. 21

Why Access Matters? Enough Rx opioids were dispensed last year to medicate every Arizona adult around the clock for more than 2 weeks 22

Percent (%) Youth Reporting Source How Access Translates into the Population 73.2% of Arizona youth who have misused Rx drugs in the past 30 days report getting them from friends, family or right out of the home 80 Percentage of Past 30 Day Youth Rx Misusers Obtaining Rx Drugs on the "Friends and Family Plan" (AYS) 78 76 74 72 70 68 66 2010 2012 2014 2016 Note: Y-Axis altered for visual purposes; accurate depiction is out of 100% 23

The CSPMP: Sign up here: https://pharmacypmp.az.gov/

Percent (%) Signed Up to Use the CSPMP Percentage of Arizona Pharmacists and Prescribers Signed Up to Use the CSPMP 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 338% Increase 334% Increase 30.0% 20.0% 10.0% 0.0% June 2012 December 2013 December 2014 December 2015 December 2016 Prescribers Pharmacists 25

WHY Opioid-Naïve Individuals? CDC MMWR, March 2017 26

High Risk Populations Criminal Justice population American Indians Former users Veterans High MEDDs and Polypharm Trauma, depression, anxiety Rural communities/counties why are they important?

Why Target Polypharm? BMJ, March 2017 28

Elevated Misuse in MH Population (NSDUH, 2015) 29

Specifically Those with Depression 30

And, Suicidal Thoughts 31

Strategic Plan STRATEGY #2: Promote responsible prescribing and dispensing policies and practices o GOAL #1: Reduce the number of opioid-naïve AHCCCS members unnecessarily started on opioid treatment o GOAL #2: Improve care processes for chronic pain and high-risk AHCCCS members. 32

Facilitate Use of Best Practices

Educate Patients http://www.azcjc.gov/acjc.web/rx/default.aspx

Project ECHO 37

Screening and Assessment Substance Use Mental Health 38

Co-Prescribing Naloxone >90 MEDDs Any combination of opioids with benzos, muscle relaxers and sleep medication Education and instructions key 39

Why MAT? Improves treatment retention Decreases opioid use Reduces risk of mortality 40

Stigma and Access to Healthcare How we talk about things impacts the way we think about things and vice versa Improved understanding that opioid use disorder is a complex interplay of biology and environment will decrease stigma and increase access to healthcare

Reward Pathway 42

Opioid Withdrawal Symptoms Pupillary dilation Tachycardia Diaphoresis Gooseflesh skin Runny nose/tearing Tremor Yawning Anxiety/irritability Restlessness Bone/joint aches GI upset

Strategic Plan STRATEGY #3: Enhance Access to Medication Assisted Treatment o GOAL #1: Assess statewide capacity of MAT providers available to AHCCCS members o GOAL #2: Increase access to integrated MAT for AHCCCS members 44

Opioid STR Grant MAT education and outreach Increase peer support services MAT COE for 24/7 access to care Hospital and ED discharge projects Diversion and incarceration alternatives Early MAT ID for re-entry population Expand residential/recovery home services 45

Thank You Shana.Malone@azahcccs.gov 46

Additional AZ Resources: Take the CME Safe & Effective Opioid Prescribing While Managing Acute & Chronic Pain -FREE for AZ only: http://www.vlh.com/azprescribing/ -Non-AZ access here: http://www.vlh.com/ Use the AZ Prescription Drug Misuse & Abuse Initiative Toolkit here (scroll down to Strategies): http://www.rethinkrxabuse.org/. Order a physical copy from Lacie Ampadu, Lacie.Ampadu@azdhs.gov Sign up for the AZ Prescription Drug Monitoring Program here (FREE & required for licensing): https://pharmacypmp.az.gov/ Use the Arizona Opioid Prescribing Guidelines here: http://www.azdhs.gov/documents/audiences/clinicians/clinical-guidelines-recommendations/prescribingguidelines/az-opiod-prescribing-guidelines.pdf. Request FREE physical copies from Lacie, Lacie.Ampadu@azdhs.gov. Request a Naloxone training and receive free Naloxone. Contact Hayley Coles to schedule at hcoles@spwaz.org. View the recorded webinar here (will post soon): http://telemedicine.arizona.edu/webinar Connect w/ county organizations working on this issue. Email Lacie, Lacie.Ampadu@azdhs.gov or Alyssa Padilla, alydilla@email.arizona.edu to connect you.

This webinar is made possible through funding provided by Health Resources and Services Administration, Office for the Advancement of Telehealth (G22RH24749). Arizona State Office of Rural Health is funded granted through a grant from US Department of Health and Human Services. Grant number H95RH00102-25-00 This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, DHHS or the U.S. Government.