K e ntuc ky’ s Opio id Use Diso rde r Crisis: A F o c us o n Rura l Po pula tio ns Alle n J. Bre nze l, M.D.,MBA Me dic a l Dire c to r, DBHDI D, CHF S Asso c ia te Pro fe sso r o f Psyc hia try a nd Pe dia tric s Unive rsity o f K e ntuc ky
K e ntuc ky - Co nte xt • Po pula tio n 4.4 millio n • E c o no mic Sta tus – 47 th in a ve ra g e a nnua l inc o me ($41,141) • Rura l Sta te – Mo re tha n 50 pe rc e nt live in rura l se tting • Me dic a id E xpa nsio n Sta te – 1.4 millio n K e ntuc kia ns o n Me dic a id – 500 tho usa nd o f tho se a re E xpa nsio n • Ce nte r o f the Opio id Crisis
AGE-ADJUSTED OVERDOSE DEATH RATE BY STATE, 2016 Age-Adjusted Crude Rate State Deaths Population Rate per per 100,000 100,000 West Virginia 884 1,831,102 48.3 52.0 Ohio 4,329 11,614,373 37.3 39.1 New Hampshire 481 1,334,795 36.0 39.0 Pennsylvania 4,627 12,784,227 36.2 37.9 Kentucky 1,419 4,436,974 32.0 33.5 Maryland 2,044 6,016,447 34.0 33.2 Massachusetts 2,227 6,811,779 32.7 33.0 Rhode Island 326 1,056,426 30.9 30.8
KY RESIDENT DRUG OVERDOSE DEATHS (all drugs) 10.3% increase 1565 1600 1419 1400 1273 1200 10071058107810191077 Numb e r o f De a ths 1000 728 708 764 769 800 638 560 526 600 426 345 400 197 241 200 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year
Composite Risk Index for Opioid Overdose
Numb e r o f Opio id-Re la te d Ove rdo se De a ths in K e ntuc ky 2017 Synthetic opioids increased to 763
E / D Ove rdo se Visits All Drug s K e ntuc ky I njury Pre ve ntio n a nd Re se a rc h Ce nte r Da shb o a rd
Ne o na ta l Opio id Withdra wa l 1,200 1,115 1,060 1,043 982 1,000 934 890 800 756 725 Number 632 600 522 379 400 327 251 209 179 200 133 123 98 69 46 19 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 NAS Hospitalizations NAS Paid by Medicaid
Consequences of Opioid Crisis • Crisis in numb e r o f individua ls inc a rc e ra te d in sta te c o rre c tio na l syste m (25,000) • Mo re tha n 9600 c hildre n in sta te c usto dy • E xplo ding he a lthc a re c o st fo r OUD re la te d he a lth c a re c o mplic a tio ns – OD E / R a nd a dmissio ns – He pa titis/ HI V Risk – Ce llulitis/ e ndo c a rditis/ b ra in a b sc e sse s
Counties most vulnerable to rapid HIV spread if HIV introduced: 220 counties in 26 states Van Handel et al. Journal of AIDS epub ahead of print DOI: 10.1097/Q AI.0000000000001098
Over 50 counties in KY vulnerable to rapid Hep C/HIV spread Van Handel et al. Journal of AIDS epub ahead of print DOI: 10.1097/Q AI.0000000000001098
K e ntuc ky Opio id Re spo nse E ffo rt BHDI D Go ve rno r’ s DPH Offic e DMS DCBS Administra tive He a lth a nd OCSHN Offic e o f the F a mily Se rvic e s OI G (K ASPE R) Co urts OHDA Justic e a nd L a b o r Pub lic Sa fe ty Offic e o f Drug Co ntro l Po lic y (ODCP) E duc a tio n a nd Wo rkfo rc e De ve lo pme nt
Building Blocks of the Action Plan
Prevention Prevent initiation of use Prevent misuse Prevent related harm
Opio id Re spo nse – F o c us o n Rura l • Rura l o pio id pre sc rib ing tre nds • Ha rm re duc tio n/ e ng a g e me nt • Ac c e ss to q ua lity tre a tme nt
Opio id Pre sc rib ing
Stra te g ie s • Ma nda to ry utiliza tio n o f PDMP (K ASPE R) • Re g ula tio n o f pa in c linic (“pill mills”) • Pro vide r/ Pub lic E duc a tio n • Drug ta ke b a c k a nd pill dispo sa l • E nha nc e d PDMP • T hre e da y limit fo r a c ute pa in • Opio id Ste wa rdship
Quesinberry, D. KASPER Quarterly Threshold Analysis Report, Fourth Quarter 2017 . Kentucky Injury Prevention and Research Center, 2018. Prevent Initiation of Use
PERCENT OF TOTAL: THE PERCENTAGE OF ALL DISPENSED C-II OPIOID ANALGESIC DRUG PRESCRIPTIONS WHERE DAY'S SUPPLY IS ≤ 3 17.00 16.69 16.62 16.38 16.50 16.16 16.03 16.01 15.85 16.00 H O U S 15.50 Proportion (%) E 14.93 B 15.00 I 14.69 14.65 L 14.63 14.54 L 14.42 14.50 3 3 3 13.91 14.00 13.50 13.00 12.50 12.00 De c Ja n F e b Ma r Apr Ma y Jun Jul Aug Se p Oc t No v De c Ja n 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018
Treatment Improve early identification of intervention need Build pathways to treatment Support utilization of a full treatment continuum Integrate and coordinate service delivery
T re a tme nt Rura l F o c us • T re a tme nt L o c a to r a nd Ca ll L ine • I nc re a se d Ac c e ss to MAT • I mpro ve me nt o f Ne two rk Ade q ua c y • Wo rkfo rc e • T e le he a lth • 1115 Wa ive r
Increase access to and awareness of treatment resources for clients and providers findhelpnowky.org Pathways to treatment
I mpro ve d Ac c e ss to Me dic a tio n Assiste d T he ra py (MAT ) ● Me tha do ne ● Bupre no rphine ● Na ltre xo ne Me dic a tio ns in c o mb ina tio n with e vide nc e b a se d the ra pie s a nd psyc ho so c ia l suppo rts
Medicaid 1115 Waiver – SUD components Grant exceptions to 15 bed limit for SUD residential Develop quality and outcome standards Consider SUD status in determining medically frail determinations Count “Recovery” activities toward Community Engagement Requirements Enhance access to employment resources
RECOVERY Expand transitional care services such as housing, transportation, employment Expand community support services to support long-term recovery
EMPLOYMENT SUPPORT • Employment supports through the Department of Corrections for individuals re-entering the community • Employer toolkit to guide employers’ understanding of OUD in the workplace and to provide best practice recommendations for prevention, treatment, and recovery support Decrease stigma and barriers
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