ENLOE MEDICAL CENTER SUBSTANCE USE NAVIGATOR PROGRAM Amanda - PDF document

3/5/2020 JM1 ENLOE MEDICAL CENTER SUBSTANCE USE NAVIGATOR PROGRAM Amanda Wilkinson, Manager, Case Management Jake Miller, Substance Use Navigator 1 BUTTE COUNTY • 2,501 individuals with an opioid use disorder (OUD) (2016) • Up to 1,319 people with OUD without access to opioid agonist treatment (2016) 17 opioid-related overdose deaths (2018) • Butte county drug induced deaths are double the state • Highest rate for non-fatal overdoses in the state • • 3.1% of prescribers in the county had a buprenorphine waiver (2018) • 35 prescribers within the county • 64 prescribers out of the county https://www.urban.org/sites/default/files/butte.pdf https://discovery.cdph.ca.gov/CDIC/Oddash/ 2 OUD COMPLICATES INPATIENT TREATMENT  25-30% of admitted patients leave AMA  Craving  Fear of mistreatment  Financial and social pressures  Withdrawal  Reduced adherence  Increased readmission  Patients with OUD on buprenorphine had reduced 30 and 90 day hospital readmission rate by 53 and 43%compared to those not on buprenorphine Lianping Ti et al. Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review AJPH, December 2015 Moreno, et al. Predictors for 30 day and 90 day hospital readmission among patients with opioid use disorder. Journal of Addiction Medicine. 2019. 3 1

Slide 1 JM1 Jake Miller, 11/12/2019

3/5/2020 DRUG RELATED DEATH RATE PER 1000 POST DISCHARGE 40. 30. 31.7 20. 14.9 10. 10.6 2 0. No hospital admission 28 days after discharge 1-3 months 3 months-1 year White S et al. Drugs-Related Death Soon after Hospital-Discharge among Drug Treatment Clients in Scotland: Record Linkage, Validation, and Investigation of Risk-Factors. ; PLoS One. 2015; 10(11): e0141073 4 DETOX DOESN’T LAST Chutuape, M et al. One-, three-, and six-month outcomes after brief inpatient opioid detoxification. The American Journal of Drug and Alcohol Abuse. Vol 27:1, 2001. 5 ADDICTION NEUROSCIENCE 101 6 2

3/5/2020 CALIFORNIA’S STRATEGY In 2017, California Department of Health Care Services (CDHCS) received the State Targeted Response to the Opioid Crisis (Opioid STR) Grant  Medication Assisted Treatment (MAT) Expansion Project  California Hub and Spoke System (CA HSS&S)  Aims to increase access to MAT services throughout the state, particularly in counties with the highest overdose rates  Increase the availability and utilization of buprenorphine  The Tribal MAT Project California Department of Health Care Services https://www.dhcs.ca.gov/Documents/State-Opioid-Response-Grant_Performance-Progress-Report-Year-1.pdf 7 HUB AND SPOKE SYSTEM H&SS aims to increase access to MAT services throughout the state, particularly in counties with the highest overdose rates.  Hub is a Narcotics Treatment Program (NTP) that specializes in treating patients with OUD  Spokes can be an FQHC, mental health center, private practice or community clinic where a buprenorphine prescriber or potential prescriber is available California Department of Health Care Services https://www.dhcs.ca.gov/Documents/State-Opioid-Response-Grant_Performance-Progress-Report-Year-1.pdf 8 CALIFORNIA STRATEGY IMPLEMENTATION  In 2018, CDHCS received the State Opioid Response (SOR) Grant. With SOR funding, CDHCS implemented the MAT Expansion Project 2.0  Increase access to MAT  Reduce unmet treatment needs  Reduce opioid overdose related deaths through prevention, treatment, and recovery services California Department of Health Care Services https://www.dhcs.ca.gov/Documents/State-Opioid-Response-Grant_Performance-Progress-Report-Year-1.pdf 9 3

3/5/2020 JM [2]2 ACCOMPLISHMENTS  For the period of September 30, 2018 through September 29, 2019:  Provided treatment to approximately 22,000 new patients  Saved approximately 7,500 lives with opioid overdose reversal medication naloxone (Narcan)  More than 240,000 naloxone kits distributed  Created 650 new access point locations where patients can receive treatment for OUD  Trained 395 new providers to prescribe buprenorphine  Established 52 hospitals and emergency rooms as centers for stabilization and referral to treatment for OUD  2,340 individuals on buprenorphine  Expanded access to treatment in jails and drug courts in 29 counties, which have provided MAT services to 1,646 clients California Department of Health Care Services https://www.dhcs.ca.gov/Documents/State-Opioid-Response-Grant_Performance-Progress-Report-Year-1.pdf 10 The California Bridge Program is developing hospitals and emergency rooms into primary access points for the treatment of acute symptoms of substance use disorders by way of motivation, resources, and encouragement for patients to enter and remain in treatment. GOAL: Ensure that people with substance use disorder receive 24/7 high-quality care in every California health system by 2025 11 CA BRIDGE ACCOMPLISHMENTS  Increased number of primary access points for Medication Assisted Treatment (MAT)  52 health care facilities across 35 counties have initiated MAT  2,060 individuals referred into treatment  4,302 individuals provided recovery services 12 4

Slide 10 JM [2]2 Jake Miller, 2/20/2020

3/5/2020 BUTTE COUNTY VS CALIFORNIA California Opioid Overdose Surveillance Dashboard; https://skylab.cdph.ca.gov/ODdash/ 13  Improves access to Medication Assisted Treatment (MAT). WHAT IS A  Embedded in Case Management and working SUBSTANCE USE in both emergency department and inpatient settings NAVIGATOR  The SUN will assist with connecting patients to (SUN)? treatment and follow-up support 14 WHAT DO SUNS DO?  Initial assessments  Introduce patients to MAT programs and services  Expedite appointments to MAT clinics  Coaching patients and on-going contact  Community collaboration activities  Process: 1. Patient with Substance Use Disorder (SUD) identified 2. SUN talks about treatment with patient SUN consults with provider to initiate treatment if possible 3. SUN guides patient through process of accessing treatment once 4. discharged 5. SUN continues to support patient after discharge to address any barriers 15 5

3/5/2020 SUN STATS  2019-2020 Fiscal Year (Q1/Q2)  Quarters 1 & 2 (7/1/19 – 12/31/19)  Total 258 patients seen  73 MAT patients, 55 MAT starts  49 Suboxone, 6 methadone  14 already engaged in MAT, 4 Vivitrol  44 patients referred to community providers by SUN  20 remain in treatment, 7 no longer attending, 16 intake “no show”  74% of patients who enrolled in services (attended intake with provider) are still engaged in treatment 16 SUN STATS (CONT’D) DRUG OF CHOICE Other Heroin ETOH Meth Poly Cannabis Cocaine/Crack Benzos Hallucinogens Other/NA Opiates Q1 (FY 19/20) 25 15 34 36 10 4 1 0 1 5 Q1 % 19.1% 11.5% 26.0% 27.5% 7.6% 3.1% 0.8% 0.0% 0.8% 3.8% Q2 (FY 19/20) 44 11 30 27 10 1 1 1 0 1 Q2 % 34.9% 8.7% 23.8% 21.4% 7.9% 0.8% 0.8% 0.8% 0.0% 0.8% TOTAL # 69 26 64 63 20 5 2 1 1 6 TOTAL % 26.9% 10.2% 25.0% 24.6% 7.8% 2.0% 0.8% 0.4% 0.4% 2.3% 32% of all patients had 18% of all patients co-occurring mental were homeless health dx 17 MAT: NO LONGER IN THE CYCLE Euphoria Normal Withdrawal Normal Tolerance & Physical Dependence Acute use Chronic use 18 6

3/5/2020  Physical dependence without addiction  Eliminate withdrawal MEDICATION  Reduce cravings EFFECTS  If a slip happens, don’t feel effects  Proper dosing  no euphoria, no sedation 19 JM2  Methadone  Full opioid agonist  Long half life  Only available in specialty clinic METHADONE VS.  Buprenorphine BUPRENORPHINE  Partial opioid agonist  Ceiling effect on sedation, respiratory depression  Available from any provider with X waiver 20 CEILING EFFECT https://www.researchgate.net/figure/Risk-of-respiratory-depression-with-opioid-agonists-partial-agonists-and- antagonists_fig3_286489121 21 7

Slide 20 JM2 Jake Miller, 11/13/2019