Coordinating Workgroup Meeting January 11, 2018 Happy New Year! - - PowerPoint PPT Presentation

NC Opioid and Prescription Drug Abuse Advisory Committee (OPDAAC)

Coordinating Workgroup Meeting

January 11, 2018 Happy New Year!

• Welcome!

−Susan Kansagra −Steve Mange

• Introductions of Attendees

−Your name −Your organization/affiliation

Welcome! and Introductions of Attendees

NC Opioid Action Plan, Measuring Impact NC Opioid Action Plan, Measuring Impact

Updat Update on

• n Metrics

Metrics

Scott Proescholdbell

Metrics f Metrics for NC’s Opioid r NC’s Opioid Action Plan Action Plan

Me Metrics trics Baseline Baseline Data Data (20 (2016, Q4) 6, Q4) 202 2021 T Trend end/Goal /Goal

OVERALL OVERALL Number of unintentional opioid-related deaths to NC Residents (ICD-10) 335 20% reduction in expected 2021 number Number of ED visits that received an opioid overdose diagnosis (all intents) 998 20% reduction in expected 2021 number

Reduce o ce over ersupply of supply of pres escript cription op ion opioid ioids

Average rate of multiple provider episodes for prescription opioids (times patients received

• pioids from ≥5 prescribers dispensed at ≥5 pharmacies in a six month period), per

100,000 residents 29.9 per 100,000 Decreasing trend Total number of opioid pills dispensed 145,997,895 Decreasing trend Percent of patients receiving more than an average daily dose of >90 MME of opioid analgesics 6.7% Decreasing trend Percent of prescription days any patient had at least one opioid AND at least one benzodiazepine prescription on the same day 25.3% Decreasing trend Reduce Divers Reduce Diversion/ n/Fl Flow of

• w of Ill

Illici cit t Drugs Drugs Percent of opioid deaths involving heroin or fentanyl/fentanyl analogues 58.7%

• Number of acute Hepatitis C cases

43 Decreasing trend Increase A ease Acce cess ss to Nalox loxone Number of EMS naloxone administrations 3,185

• Number of community naloxone reversals

817 Increasing trend Treatm Treatment and Recovery ent and Recovery Number of buprenorphine prescriptions dispensed 133,712 Increasing trend Number of uninsured individuals and Medicaid beneficiaries with an opioid use disorder served by treatment programs 15,187 Increasing trend Number of certified peer support specialists (CPSS) across NC 2,352 Increasing trend

100 200 300 400 500 600 700 Number of deaths per quarter

Number of Unintentional Opioid-R mber of Unintentional Opioid-Related Deaths to elated Deaths to NC R NC Residents sidents

GOAL

Goal: 20% reduction from expected

2021 Q4 expected deaths based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC State Center for Health Statistics, Vital Statistics-Deaths, ICD10 coded data, includes NC Resident deaths occurring out of state, 1999-2017 Q1 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual deaths

200 400 600 800 1,000 1,200 1,400 1,600 1,800 Number of ED visits per quarter

Number of Opioid Over mber of Opioid Overdose ED Visits dose ED Visits

2021 expected rate based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Division of Public Health, Epidemiology Section, NC DETECT, 2009-2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual ED visits

GOAL

Goal: 20% reduction from expected

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Rate per 100,000 residents per six-months

Average Rate of multiple pr Average Rate of multiple provider

• vider episodes f

episodes for prescription opioids r prescription opioids (times patients received opioids fr (times patients received opioids from

• m ≥5 prescriber

5 prescribers dispensed at s dispensed at ≥5 5 pharmacies in a pharmacies in a Six month period), per 1 Six month period), per 100,000 residents 00,000 residents

2021 expected rate based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Division of Mental Health, Controlled Substance Reporting System, 2011-2017 Q2 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual rate

50,000,000 100,000,000 150,000,000 200,000,000 250,000,000 Number of opioid pills dispensed per quarter

Total N l Number of Opioid Pills Dispensed mber of Opioid Pills Dispensed

2021 expected pills dispensed based

• n 2013-2016

trend

*2017 data are preliminary and subject to change Source: NC Division of Mental Health, Controlled Substance Reporting System, 2011-2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual pills dispensed

0% 5% 10% 15% 20% 25% Percent per quarter

Per Percent of patients recei ent of patients receiving more than an average daily g more than an average daily dose of >90 MME of opioid analgesics dose of >90 MME of opioid analgesics

2021 expected percent based on 2013-2016 trend

*2017 data are preliminary and subject to change **This update excludes patients receiving Buprenorphine and Methadone; the June 2017 Version 1 metric did not make these exclusions Source: NC Division of Mental Health, Controlled Substance Reporting System, 2011- 2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Updated December 2017

Actual percent

0% 10% 20% 30% 40% 50% Percent per quarter

Per Percent of prescription days ent of prescription days any any patient had at least one opioid patient had at least one opioid AND at least one benzodiazepine AND at least one benzodiazepine prescription on the same day prescription on the same day

2021 expected percent based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Division of Mental Health, Controlled Substance Reporting System, 2011- 2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Updated December 2017

Actual percent

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent per quarter

2021 expected percent based on 2013-2016 trend Actual percent

*2017 data are preliminary and subject to change **Increasing numbers of deaths due to other classes of designer opioids are expected Source: NC Office of the Chief Medical Examiner (OCME) and the OCME Toxicology Laboratory, 2010-2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Per Percent of Opioid Deaths Involving Her ent of Opioid Deaths Involving Heroin or in or Fent Fentanyl/Fent nyl/Fentanyl Analogues anyl Analogues

Number of Acute Hepatitis mber of Acute Hepatitis C Cases C Cases

2021 expected number based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Division of Public Health, Epidemiology Section, NC EDSS, 2000-2017 Q1 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual cases

10 20 30 40 50 60 70 80 90 Number of cases per quarter

500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 Number of administrations per quarter

Number of EMS Naloxone Administr mber of EMS Naloxone Administrations tions

2021 expected number based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Office of Emergency Medical Services (OEMS), EMSpic-UNC Emergency Medicine Department, 2010-2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual administrations

500 1,000 1,500 2,000 2,500 3,000 Number of reported reversals per quarter

Number of R mber of Repor ported Community Naloxone R ed Community Naloxone Rever versals sals

2021 expected number based on 2013-2016 trend

Source: NC Harm Reduction Coalition (NCHRC), 2013 Q3- 2017 Q3 Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual reversals

50,000 100,000 150,000 200,000 250,000 Number of prescriptions per quarter

Number of Buprenor mber of Buprenorphine Prescriptions Dispensed phine Prescriptions Dispensed

2021 expected number based on 2013-2016 trend

*2017 data are preliminary and subject to change Source: NC Division of Mental Health, Controlled Substance Reporting System, 2011-2017 Q3 Previously, trendline calculations began in 2010; trendline calculations now start in 2013 due to the increased availability of illicitly manufactured fentanyl beginning around that time. Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

Actual prescriptions

2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 Number of individuals per quarter

Number of Uninsured Individuals Number of Uninsured Individuals and and Medicaid Benef Medicaid Beneficiaries ciaries with an with an Opioid Use Disor Opioid Use Disorder Ser der Served by ed by Treatment Pr eatment Programs

• grams

*2017 data are preliminary and subject to change **This update includes a broader set of claims data than the June 2017, Version 1 metric Source: NC Division of Mental Health, Claims Data, 2013 Q3- 2017 Q3 Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

ICD-9-CM ICD-10-CM

Number of Cer Number of Certif ified Peer Suppor ied Peer Support Speci t Speciali alists (CPSS) ts (CPSS) Acr Across NC ss NC

*2017 data are preliminary and subject to change Source: UNC-Chapel Hill, School of Social Work, Behavioral Health Springboard, 2010-2017 Q3 Detailed technical notes on all metrics available from NC DHHS; Data now depicted quarterly; Updated December 2017

500 1,000 1,500 2,000 2,500 3,000 Number of CPSS

Rates of Unintentional/Undetermined Prescription Opioid Overdose Deaths & Outpatient Opioid Analgesic Prescriptions Dispensed

North Carolina Residents, 2011-2015

Source: Deaths‐ N.C. State Center for Health Statistics, Vital Statistics, 2011‐2015, Overdose: (X40‐X44 & Y10‐Y14) and commonly prescribed opioid T‐codes (T40.2 and T40.3)/Population‐National Center for Health Statistics, 2011‐ 2015/Opioid Dispensing‐ Controlled Substance Reporting System, NC Division of Mental Health, 2011‐2015 Analysis: Injury and Epidemiology Surveillance Unit

Average mortality rate: 6.4 per 100,000 persons Average dispensing rate: 82.9 Rx per 100 persons

Rates of Unintentional Overdose Deaths & Outpatient Opioid Analgesic Pills Dispensed, by County, North Carolina

Residents, 2012-2016

Source: Deaths‐ N.C. State Center for Health Statistics, Vital Statistics, 2012‐2016, Overdose: (X40‐X44 & Y10‐Y14) and commonly prescribed opioid T‐codes (T40.2 and T40.3)/Population‐National Center for Health Statistics, 2011‐ 2015/Opioid Dispensing‐ Controlled Substance Reporting System, NC Division of Mental Health, 2016 Analysis: Injury and Epidemiology Surveillance Unit

ALAMANCE ALEXANDER ALLEGHANY ANSON ASHE AVERY BEAUFORT BERTIE BLADEN BRUNSWICK BUNCOMBE BURKE CABARRUS CALDWELL CARTERET CASWELL CATAWBA CHATHAM CHEROKEE CHOWAN CLAY CLEVELAND COLUMBUS CRAVEN CUMBERLAND CURRITUCK DARE DAVIDSON DAVIE DUPLIN DURHAM EDGECOMBE FORSYTH FRANKLIN GASTON GATES GRAHAM GRANVILLE GREENE GUILFORD HALIFAX HARNETT HAYWOOD HENDERSON HERTFORD HOKE IREDELL JACKSON JOHNSTON JONES LEE LENOIR LINCOLN MACON MADISON MARTIN MCDOWELL MECKLENBURG MITCHELL MONTGOMERY MOORE NASH NEW HANOVER NORTHAMPTON ONSLOW ORANGE PAMLICO PASQUOTANK PENDER PERQUIMANS PERSON PITT POLK RANDOLPH RICHMOND ROBESON ROCKINGHAM ROWAN RUTHERFORD SAMPSON SCOTLAND STANLY STOKES SURRY SWAIN TRANSYLVANIA UNION VANCE WAKE WARREN WATAUGA WAYNE WILKES WILSON YADKIN YANCEY

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 Overdose Death Rate (per 100,000) Opioid Pills Dispensed (per person)

Source: Deaths‐N.C. State Center for Health Statistics, Vital Statistics, 2012‐2016, Any mention of T40.0 (opium), T40.2 (Other Opioids), T40.3 (Methadone) and/or T40.4 (Other synthetic opioid) and unintentional intent (X40‐X44)/Population‐National Center for Health Statistics, 2012‐2016 Analysis by Injury Epidemiology and Surveillance Unit

Unintentional Opioid-related Death Rates by County

per 100,000 North Carolina Residents, 2012-2016

Statewide mortality rate (2012- 2016): 9.2 per 100,000 persons

Unintentional Opioid-related Overdose Death Rates by County*, County*, North Carolina Residents, 2012-2016

5 10 15 20 25 30 35

CHATHAM DUPLIN ANSON LENOIR ORANGE NORTHAMPT… DURHAM MONTGOMERY MARTIN WAKE HOKE UNION CASWELL PERSON MECKLENBU… WILSON ALAMANCE WAYNE JOHNSTON PASQUOTANK SWAIN CURRITUCK PERQUIMANS PITT GUILFORD HARNETT BERTIE MOORE MACON ONSLOW GATES CHEROKEE BEAUFORT FRANKLIN HALIFAX ROBESON WATAUGA EDGECOMBE CUMBERLAND BUNCOMBE MADISON HENDERSON CHOWAN JACKSON CABARRUS POLK CLEVELAND STANLY JONES LEE IREDELL FORSYTH SCOTLAND DARE SAMPSON BLADEN NASH GRANVILLE CLAY ROCKINGHAM CATAWBA CRAVEN COLUMBUS RUTHERFORD SURRY VANCE LINCOLN ALEXANDER ASHE TRANSYLVANIA MCDOWELL DAVIE RANDOLPH HAYWOOD PENDER DAVIDSON RICHMOND STOKES AVERY CALDWELL CARTERET PAMLICO NEW HANOVER ROWAN ALLEGHANY GASTON MITCHELL YANCEY YADKIN BRUNSWICK BURKE WILKES

Rate per 100,000 persons

Source: Deaths‐N.C. State Center for Health Statistics, Vital Statistics, 2012‐2016, Any mention of T40.0 (opium), T40.2 (Other Opioids), T40.3 (Methadone) and/or T40.4 (Other synthetic opioid) and unintentional intent (X40‐X44)/Population‐National Center for Health Statistics, 2012‐2016 Analysis by Injury Epidemiology and Surveillance Unit *Rates suppressed for counties with <5 deaths

County Opioid-related

• verdose rate per

100,000 (2012-2016)

Chatham 2.32 Duplin 2.35 Anson 3.86 Lenoir 4.45 Orange 4.70 Northampton 4.85 Durham 4.90 Montgomery 5.09 Martin 5.10 Wake 5.10

County Opioid-related

• verdose rate per

100,000 (2012-2016)

Wilkes 30.78 Burke 22.79 Brunswick 20.13 Yadkin 19.04 Yancey 18.17 Mitchell 17.02 Gaston 16.81 Alleghany 16.53 Rowan 16.28 New Hanover 16.07

Source: Deaths‐N.C. State Center for Health Statistics, Vital Statistics, 2012‐2016, Any mention of T40.0 (opium), T40.2 (Other Opioids), T40.3 (Methadone) and/or T40.4 (Other synthetic opioid) and unintentional intent (X40‐X44)/Population‐National Center for Health Statistics, 2012‐2016 Analysis by Injury Epidemiology and Surveillance Unit

Rate of Outpatient Opioid Pills Dispensed by County

per North Carolina Resident, 2016

Source: Opioid Dispensing – NC Division of Mental Health, Controlled Substance Reporting System, 2016/ Population‐ National Center for Health Statistics, 2016 Analysis: Injury Epidemiology and Surveillance Unit

Statewide dispensing rate (2016): 66.5 pills per resident

Opioid overdose is more common in counties where more pills are dispensed.

Rate of Outpatient Opioid Pills Dispensed by County, North Carolina Residents, 2016

Source: Opioid Dispensing – NC Division of Mental Health, Controlled Substance Reporting System, 2016/ Population‐ National Center for Health Statistics, 2016 Analysis: Injury Epidemiology and Surveillance Unit

20 40 60 80 100 120 140 160

ORANGE MECKLENBURG DURHAM WAKE GATES CURRITUCK HOKE CHATHAM CASWELL UNION WATAUGA GUILFORD MCDOWELL WARREN CAMDEN GREENE GRANVILLE JOHNSTON PASQUOTANK ONSLOW HERTFORD FORSYTH PERQUIMANS PITT CUMBERLAND EDGECOMBE FRANKLIN WAYNE JONES HYDE CABARRUS WILSON ALAMANCE DUPLIN NORTHAMPTON STATE CHOWAN JACKSON NEW HANOVER TYRRELL ANSON BUNCOMBE IREDELL DARE POLK LENOIR HARNETT MARTIN DAVIDSON HALIFAX HENDERSON NASH AVERY MOORE PENDER TRANSYLVANIA WASHINGTON BERTIE DAVIE VANCE STANLY LEE SAMPSON ROWAN RANDOLPH ALLEGHANY LINCOLN ASHE BRUNSWICK PAMLICO MONTGOMERY HAYWOOD CRAVEN GASTON CATAWBA ALEXANDER YANCEY CLEVELAND WILKES CLAY PERSON CARTERET SURRY STOKES BLADEN YADKIN CHEROKEE GRAHAM BEAUFORT SWAIN RUTHERFORD ROBESON MITCHELL ROCKINGHAM SCOTLAND BURKE CALDWELL MADISON RICHMOND COLUMBUS MACON

Rate per person

County Outpatient opioid pills dispensed per person (2016)

Orange 34.8 Mecklenburg 36.7 Durham 37.7 Wake 38.7 Gates 40.9 Currituck 44.1 Hoke 45.2 Chatham 45.7 Caswell 46.2 Union 47.2

County Outpatient opioid pills dispensed per person (2016)

Macon 151.9 Columbus 144.1 Richmond 137.5 Madison 134.2 Caldwell 121.9 Burke 120.9 Scotland 118.8 Rockingham 118.7 Mitchell 117.9 Robeson 116.5

Source: Opioid Dispensing – NC Division of Mental Health, Controlled Substance Reporting System, 2016/ Population‐ National Center for Health Statistics, 2016 Analysis: Injury Epidemiology and Surveillance Unit

Looking Ahead: 20 Looking Ahead: 2018 18 OPD OPDAAC Policy Policy Priorities Priorities

Steve Mange

NC Harm Reduction Coalition

Fair Chance Hiring Universal pharmacy sales of syringes Lift ban on state funding for syringes

Tessie Castillo

Child Fatality Task Force

Disposal Funding for SBI/Operation Medicine Drop

Kella Hatcher

Division of Medical Assistance

Medicaid Transformation

Nancy Henley

1 2 3

Focus on health of the whole person

30

North Carolina’s Health Care System Priorities

Support providers in delivering high-quality care at good value Improve the health and well-being

• f North Carolinians

Measurably improve health

31

North Carolina’s Goals for Medicaid Managed Care

Maximize value to ensure program sustainability Increase access to care

1 2 3

• Released 2 Requests for Information
• Released proposed PHP capitation rate setting methodology
• Released 2 concept papers: Behavioral Health I/DD Tailored

Plans & Supplement Payments

• Submitted amended 1115 waiver application to CMS

Publish additional concept papers Procure centralized credentialing & enrollment broker vendors Anticipated CMS approval:

• Expenditure authority to pay for substance use disorder

services in an IMD

• Amended waiver application

Release Request for Proposal Managed care Phase 1 goes live; waiver effective for 5 years

13

Transformation milestones

* Assuming timely CMS approval and other activities

• Nov. 2017

Early 2018 2018

• Feb. 2018

Spring 2018* July 2019*

33

To share comments, email:

Medicaid.Transformation@dhhs.nc.gov

For NC Medicaid managed care information and documents:

www.ncdhhs.gov/nc-medicaid-transformation

Care4Carolina

Health Care Coverage

Carla Obiol

HB HB 662: 662:Car Carolina Car Cares

• Proposal to cover low income working North Carolinians in the Gap
• All individuals below 138% FPL eligible for Medicaid
• For individuals above 50% FPL, there is a premium (2% of income)
• Hardship exceptions possible for those who can’t afford premiums
• Lockout after 60 days of non‐payment
• Must pay back premiums to re‐enroll
• Requirement for mandatory employment activities
• “Participants must be employed or engaged in activities to promote employment”
• Work requirement exceptions possible for caretakers, medically frail, & those w/ SUD
• Copayments for services
• Requirement for “preventative care and wellness activities”
• Federal funds would finance the majority of the program
• State share would be funded through provider assessments and premium payments

C4C C4C Pl Plans ans fo for 2018 2018

• Hold additional Regional Leadership Forums –2017; Rockingham,

January, 2018; Pitt, Duplin, and Forsyth ‐ TBD.

• Hold Regional Grassroots Advocacy Trainings – Greensboro, January

16; and Raleigh, January 24, 2018. There are plans to offer additional trainings.

• Hold Advocacy Day – N.C. General Assembly, May, 2018

Federal Priorities, Barriers

Walker Wilson

Local Policy Opportunities

Nidhi Sachdeva

Local Policy Opportunities for Counties

• Engage with health systems: Promote comprehensive

approaches to pain management/opioid stewardship

• Support training/staffing for EMS to engage overdose

victims in follow up treatment/recovery and care support

• Establish and fund syringe exchange programs
• Support pharmacies to dispense naloxone under standing
• rder and referral to treatment/recovery
• Establish Law Enforcement Assisted Diversion programs
• Promote drug take back events/and awareness

−Operation Medicine Drop and Lock your Meds media campaign

39

Local Policy Opportunities for Counties

• Promote law enforcement OD identification and response

training and carrying naloxone

• Implement fair chance/Ban the Box hiring practices which

reduce crime, recidivism, boost tax contributions

−Delay employment application questions regarding person’s criminal record until after applicant has had a chance to demonstrate skills, qualifications, and rehabilitation

• Align transportation plans, services, and public transit

routes with treatment opportunities and recovery supports in community

40

• How can we support each other’s legislative goals?
• What are our next steps as a collective?

Group Discussion

Wr Wrap up, THANK Y ap up, THANK YOU!, and What’s next U!, and What’s next

• Reminder:

−Points-of-contact for Action Plan reporting, please fill in Google spreadsheet by January 19

• Next OPDAAC Coordinating Meetings

−February 8 at NC Hospital Association −April 12

• Next Full OPDAAC Meeting

−March 16, 2018 at NC State McKimmon’s Center