35 th Annual Alaska Health Summit Public Health Approaches to Substance Misuse and Addictions Jay C. Butler, MD, FAAP, MACP, FIDSA Chief Medical Officer, Alaska Dept of Heath & Social Services Director, Division of Public Health
Overview Background: population Public health approaches Multi-level Multi-sectoral Multi-molecular
21 st Century Health Threats HIV, SEXUALLY TRANSMITTED INFECTIONS, VIRAL HEPATITIS SELF-HARM AND INTERPERSONAL VIOLENCE LOW EDUCATIONAL ATTAINMENT LIMITED ACCESS TO CARE POVERTY MENTAL ILLNESS SUBSTANCE MISUSE AND ADDICTIONS SOCIAL ISOLATION HUMAN TRAFFICKING HISTORIC TRAUMA ADVERSE CHILDHOOD EXPERIENCES HOMELESSNESS IMPRISONMENT AND RECIDIVISM
Drivers of Changes in Life Expectancy, US, From 2000 to 2015 Dowell D, et al. JAMA 2017; 318:1065-1067
Economic Impact of Drug and Alcohol Misuse, Alaska, 2010 2009 NSDAH: 55,700 Alaskans dependent on or misusing 9.5% of persons 12 yr) Total cost to Alaska economy: $1.2 B $217.7 M $237.3 M $673.2 M $13.2 M McDowell Group, 2012 $50.0 M
Age-adjusted Drug Overdose Death Rates, US, 1999-2016 Hedegaard H, et al. NCHS Data Brief no. 294, 2017
Opioid-Related Overdose Deaths, Alaska, 2012-17 120 100 80 60 40 20 Death Involving** Any Opioid Prescription Pain Reliever Heroin Fentanyl 2016 rate: 12.9/100,000 0 2012 2013 2014 2015 2016 2017* * Preliminary (through Jan 3, 2018) ** Many deaths involve >1 substance
Purity (percent by weight) Price (per mg pure) Purity and Price of Mexican Origin Retail Heroin, U.S., 2011-2015 35 Purity Price 1.6 30 25 20 15 10 5 1.4 1.2 1 0.8 0.6 0.4 0.2 0 2011 2012 2013 2014 2015 0 DEA Intelligence Report: 2015 Heroin Domestic Monitoring Program. Oct 2017
Counterfeit 30mg generic oxycodone containing fentanyl, Tennessee Counterfeit Norco (hydrocodone and acetaminophen) containing primarily fentanyl and promethazine, California Counterfeit Percocet (oxycodone and acetaminophen) containing cyclopropyl fentanyl and U-47700, Georgia
Substance Misuse and Addictions: Multi-Level Prevention Public Health Practice Paradigms Acute Health Event Control and Prevention
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Phylodynamic Analysis of Viral Genetic and Epidemiological Data, HIV Cases (n=183) Scott Co., IN HIV Cases Diagnosed Simulated Incidence Transmission began in 2011 (sexual Tx) Exponential spread began in mid-2014 (sexual and needle sharing) Campbell EM, et al. J Infect Dis 2017; 216:1053-62
Substance Misuse and Addictions: Multi-Level Prevention Public Health Practice Paradigms Acute Health Event Control and Prevention
1. Voters make decisions based on facts 2. Addiction is a moral failure 3. Opioids are effective for treating chronic back pain 4. Statistically significant means strong scientific evidence 5. Placebos are useless 6. Exercise is the best solution for obesity 7. Homeopathy works 8. We need a debate about climate change. Vox.com
Addiction: A Chronic, Relapsing Health Condition Involving the Brain McLellan AT, et al. JAMA 2000; 284:1689-95
Conceptual Framework of Opioid Tolerance and the Role of MAT in Management
Benefits of Medication-Assisted Treatment for Opioid Use Disorders Lower relapse Decreased overdose and all-cause mortality Reduced acquisition of HIV and HCV Improved social functioning Greater retention in rehabilitation programs Schuckit MA. N Engl J Med 2017; 375(4):357-368 Sordo L, et al. BMJ 2017; 357:j1550
National Principles of Care Routine screenings for SUD in every medical setting A personal treatment plan for every patient Fast access to treatment Disease management, as with other chronic conditions Coordinated care for all illnesses Behavioral health care from legitimate providers Access to medication-assisted treatment Support for recovery in the community https://www.shatterproof.org/national-principles-care
Past Year Substance Use Disorder and Mental Illness, US Adults Aged 18 Years, 2015
Per 1,000 Members OUD Diagnoses and MAT Among Blue Cross-Blue Shield Members Rate of OUD diagnoses increased 493%, 2010-16 Only 65% of Members With OUD Received MAT in 2016 Blue Cross Blue Shield Blue Health Intelligence, June 29. 2017
We should not consider people who hold jobs, reengage with their families, and regain control over their lives through treatment that uses medications to be addicted. Rather, we should consider them to be role models in the fight against the opioid epidemic. FDA Commissioner Scott Gottlieb, MD Oct 25, 2017 Testimony to House Committee on Energy and Commerce
https://vimeo.com/235831149
Substance Misuse and Addictions: Multi-Level Prevention Public Health Practice Paradigms Acute Health Event Control and Prevention Environmental Controls and Social Determinants
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Huffington Post
Providers Registered with Alaska PDMP and Patient Profile Inquiries, Oct 2016-Nov 2017 Preliminary data
Number of Schedule II-IV Controlled Substances Entered Into PDMP Each Month Preliminary data
Medicaid Claims for Opioid Pain Relievers, Alaska, 2017 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Schedule II/III Opioid Pain Relievers Tramadol 8192 7699 7242 7387 7644 7293 7232 6340 6293 5489 5414 1097 1025 1177 1084 1125 1150 975 1118 835 974 789 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Alaska Medicaid Program, unpublished
Opioid Prescribing Rates by County Vary By Up to Six-Fold Guy GP, et al. MMWR 2017; 66(26):697-704
Subjective Pain Score RCT of 410 Pts: Management of Extremity Pain (Sprain, Fracture, MS Pain) in the ED 10 9 8 7 6 5 4 3 2 1 0 Baseline 1 hour 2 hour Ibuprofen 400mg + Acetaminophen 1000mg Oxycodone 5mg + Acetaminophen 325mg Hydrocodone 5mg + Acetaminophen 325mg Codeine 30mg + Acetaminophen 300mg 1 Endpoint: Decline in score at 2 hours (p=0.053) Chang AK, et al. JAMA 2017; 318(17):1661-67
Effect of Prescribing Guidelines on Post- Surgical Opioid Prescribing No increase in refill requests Howard R, et al. JAMA Surg 2017; published ahead of print Dec 6, 2017
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http://law.alaska.gov/pdf/admin/publicsafetyactionplan.pdf Four pillars: 1. Improving outcomes in the criminal justice system 2. Identifying public safety resource needs, particularly for rural areas 3. Improving access to mental health and substance misuse treatment 4. Addressing the opioid epidemic and drug trafficking
Cross-Sectoral Collaboration is Key Public Health Agencies Attorneys General Offices Justice and Corrections Medical Boards Healthcare Providers Hospitals and Clinics Community Coalitions Businesses and Labor Media Emergency Medical Services Social Services Agencies Faith Communities Pharmaceutical Industry Educators Third-Party Payers Others
Governor Alaska Opioid Response Incident Command System Opioid Response Multi-Agency Coordination (MAC) Group: Possible Participants Governor s Office DCCED DHSS DEED DOC DPS Opioid Response Incident Commander Opioid Response Deputy IC Alaska Criminal Information & Analysis Center State Disaster Declaration February 14, 2017 Administrative Order 287 DOL Local/Tribal Entities Federal Entities Public Information Officer Liaison Officer Multi-agency approach Local, Tribal, State, Federal, and Non-Governmental Agencies Multi-Agency Coordination (MAC) Group Incident Command System Opioid Response Operations Section Law Enforcement Opioid Response Logistics Section Procurement and Transportation Opioid Response Planning Section Situation Unit Opioid Response Finance Section SOA Grants Alaska Criminal Information and Analysis Center Community Based Prevention Documentation Unit Joint Information System Provider and Public Education Federal Grant Tracking Opioid Use Disorder Treatment Opioid Response Joint Information Team Criminal Justice Populations Governor s Office / DHSS / DPS / DOC / DCCED / DEED / DOL Prescription Drug Monitoring Prog School Based Prevention/Education
Emergency and Disaster Declarations: Purposes Personnel: deployment, intra-agency reassignment, cross-agency embedding Pay: access to emergency funds, appropriation of additional funds Procedures: streamlining of bureaucratic functions Procurement: fast-tracking and use of non-traditional methods Policy: new laws and regulations to support long-term response and recovery Priority: statement of importance, rhetorical tool Play together well
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Scope of Substance Misuse and Addictions Legal Substances Alcohol, Marijuana Illicit Substances Heroin, Methamphetamines, Synthetic Cannabinoids, Cathinones Therapeutic Substances and Prescription Drugs Opioids, Amphetamines, Benzodiazepines Emerging Technologies Powdered Alcohol, Vaping Devices, Designer Psychoactives
Price and Purity of Methamphetamine, US Source: DEA (unclassified)
Methamphetamine-Related Deaths (3-Year Moving Averages), Alaska, 2008-16 n=233 Alaska Epidemiol Bull Rec Rep, Nov 7, 2017
What Will Success Look Like? Near horizon (next 3 years) Reduced deaths from drug overdose; less NAS Declines in motor vehicle crashes from impaired driving Fewer self-injection related HIV and HCV infections Less unintentional injuries and self-harm related to drugs and alcohol Further horizons Lower rates of drug misuse and addiction, including underage use Reduced drug- and alcohol-related incarceration and re-incarceration of persons with addictions Lower rates of crime and referrals to child protective services Less interpersonal violence, self-harm, and child neglect Prevention of excessive prescriptions for controlled substances while improving wellness and function 55