Addressing Challenges Together, One Rock at a Time PAMELA SCHWEITZER, PHARM.D., BCACP ASSISTANT SURGEON GENERAL REAR ADMIRAL (RADM), U.S. PUBLIC HEALTH SERVICE E-MAIL: PAMELA.SCHWEITZER@CMS.HHS.GOV @USPHSPHARMACY
Historic Chilkoot Trail (33 miles): Golden Staircase
Department of Health and Human Services (DHHS) Hubert Humphrey Building
USPHS Commissioned Officers 6,700
Where We Serve 26 Agencies
AANP CHRONIC PAIN SEMINAR HHS Opioid Strategy Advancing the practice of pain management Improving access to treatment and recovery services Targeting availability and distribution of overdosereversing drugs Supporting cutting-edge research Strengthening timely public health data and reporting
Surgeon General Initiatives National Prevention Strategy https://addiction.surgeongeneral.gov/
#TurnTheTide http://turnthetiderx.org/#
Culture of Health The greatest medicine of all is to teach people how not to need it. http://www.cultureofhealth.org/en.html
Public Health Excellence in Interprofessional Education Collaboration Award
Action areas Quadruple AIM improving population health, increasing patient satisfaction, reduced health care spending, address clinician and staff satisfaction. Sharing experiences and ideas ongoing Academic detailing see VA model - https://www.pbm.va.gov/pbm/academicdetailingservicehome.asp Collaboration with other members of health care team social workers, physical therapists Creating a virtual healthcare team Community/Stakeholder involvement regional/county Improve use of Prescription Drug Monitoring Program (PDMP) Prescriber use mandates, delegation, unsolicited reports, real-time PDMP updates, online/streamlined registration Workflow integration Improve use of technology Identify policies or regulation changes that need to occur.
Increases in Rx opioid prescribing coincide with increases in Rx opioid overdose deaths 8 KG ME per 10,000 Pop Rx Opioid Overdose Deaths per 100,000 Pop 7 6 5 Rate 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: Analysis of CDC National Vital Statistics Data and DEA ARCOS data,1999-2015.
Source: JONES CM Analysis of the NSDUH 2002-2015, PUF Opioid Use Disorder Trends 3,000,000 Any Opioid Use Disorder Prescription Opioid Use Disorder Heroin Use Disorder 2,500,000 Number of Individuals 2,000,000 1,500,000 1,000,000 500,000 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Opioid overdose deaths by sex, 2015 7 Male Female 6 Rate per 100,000 population (age-adjusted) 5 4 3 2 1 0 Prescription Opioids Heroin Synthetic Opioids (e.g., fentanyl) Source: CDC, NVSS, 2016
Synthetic opioid deaths closely linked to illicit fentanyl supply NFLIS Fentanyl Exhibits Synthetic Opioid Overdose Deaths 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: DEA and CDC NVSS 2017.
Changes in prescribing and use trends resulted in increased morbidity and mortality High dose prescribing Longer duration Prescribing for conditions not likely to benefit from opioids Opioid and benzodiazepine combination Small number of prescribers account for disproportionate share of prescribing Multiple providers/multiple pharmacies
CDC Guidelines Non-opioid treatments preferred for chronic pain Establish treatment goals before starting opioid therapy Discuss benefits and risks before and throughout treatment Prescribe IR opioids over ER/LA opioids Start with lowest dose, reassess when considering doses 50 MME and avoid doses 90 MME or justify For acute pain - 3 days of tx often sufficient, rarely more than 7 days needed Evaluate benefits/harms within 1-4 weeks of starting tx or dose increase; at least every 3 months thereafter Incorporate risk mitigation strategies and consider naloxone for patients at increased risk for OD Check PDMP when starting tx and periodically thereafter UDTs before starting tx and at least annually Avoid prescribing benzos and opioids Offer or arrange for MAT for patients with OUD Reference: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Source: Jones CM 2016 NSDUH PUF People with opioid use disorders are not receiving treatment 3,000,000 2,500,000 2,412,106 Number of Individuals 2,000,000 1,500,000 1,000,000 500,000 744,809 546,970 0 Opioid Use Disorder Any Past Year Treatment Past Year Treatment at Specialty Facility
Most states have implemented naloxone access laws or regulations Source: https://naspa.us/resource/naloxone-access-community-pharmacies/
Pharmacy dispensing of naloxone in the US, 2010-2015 5000 4500 all other naloxone products naloxone 2mg/2ml Evzio Number of Prescriptions Dispensed 4000 3500 3000 2500 2000 1500 1000 500 0 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Quarter Jones CM et al. 2016. Increase in naloxone prescriptions dispensed in US retail pharmacies since 2013. AJPH 106:689-90
Expanding Scope of Pharmacy Practice Reference: CMCS Bulletin, January 17, 2017
States with CPA Provisions Based on data collected by NASPA, 6/2017 AK HI CA OR WA NV ID UT AZ MT WY CO NM ND SD NE MN WI IA IL KS MO OK AR MI IN OH KY TN NY PA WV VA NC SC VT ME NH MA RI CT NJ DE MD DC MS AL GA TX LA Have CPA authority in any setting FL Do not allow initiation of new therapy under CPA Only allowed in hospital setting No CPA authority for pharmacists
EHR Workflow Integration
PDMP as a Platform Increase clinical effectiveness: - risk identification, incorporate other data - validated analytics - access to resources, treatment and patient engagement - care coordination, pain contracts
Pharmacist e-care Plan https://www.healthit.gov/techlab/ipg/node/4/submission/1376
Smart Medication Monitoring and Management Technology Enabled Care Smart Patch Date/time applied Duplicate patch? Temperature Expiration date Wireless data transfer Smart Package Pill removed Date/time log Temperature Expiration date Wireless data transfer Data flowing back from Smart medications are presented in exception management dashboards for review by Care Team members 29
Medicaid - Transformed Medicaid Statistical Information System (T-MSIS) Patient Centered Outcomes Research funding to help prepare T-MSIS data for use by researchers in two primary focus areas: birth outcomes and opioids Medicaid claims data to support cutting edge research as part of HHS overall strategy to address the opioid epidemic. The use of Medicaid claims data will allow researchers to design studies to tailored to beneficiaries with Substance Use Disorders (SUD), identify adverse care patterns (i.e., use of ED to treat SUDs, opioid RX + diagnosed opioid addiction, etc.), and summarize treatment patterns (i.e., Medication Assisted Treatment utilization, therapy/counseling usage, etc.). The use of Medicaid claims data may also be able to assist with current patient centered outcome research. Linking Medicaid Claims data to other parts of the Department like CDC, SAMSHA, and NIH may also support other key HHS strategies, including strengthening public health surveillance, advancing the practice of pain management, improving access to treatment and recovery services, and targeting availability and distribution of overdose-reversing drugs.
Waiting for the right wave
Wipe outs
Easy waves/wins
Working Together
RADM Pamela Schweitzer Assistant Surgeon General U.S. Public Health Service E-mail: pamela.schweitzer@cms.hhs.gov @USPHSPharmacy