Nevadas Evolving Opioid Crisis: Successes and Challenges STEPHANIE - - PowerPoint PPT Presentation

Nevada’s Evolving Opioid Crisis: Successes and Challenges

STEPHANIE WOODARD, PSY.D. DHHS SENIOR ADVISOR ON BEHAVIORAL HEALTH KEITH CARTER, HIDTA YENH LONG, PHARM.D., BCACP NEVADA STATE BOARD OF PHARMACY

What’s HIDTA? High Intensity Drug Trafficking Area

Functions under the executive office of the President Office of National Drug Control Policy (ONDCP)

HIDTA – Designated by Congress

• A coalition of federal, state, and local law enforcement agencies
• 17 TASK FORCES in Nevada working on drugs, gangs, violent crimes
• Intelligence, Training and Prevention Programs

Nevada HIDTA values partnership, innovation, leadership and excellence

National Drug Control Strategy

This Strategy is focused on achieving one overarching strategic objective: Building a stronger, healthier, drug free society today and in the years to come by drastically reducing the number of Americans losing their lives to drug addiction in today’s crisis.

How will this be done?

• Preventing the start of drug use
• Providing treatment services leading to long-term recovery for those suffering

from addiction

• Aggressively reducing the availability of illicit drugs in America’s communities.

What are the strategies?

• Develop “evidence” based programs
• Expand the Use of Prescription Drug Monitoring Programs
• Eliminating Barriers to Treatment Availability
• Improve the Response to Overdose
• Leverage the Full Capabilities of Multi-Jurisdictional Task Force Enforcement

Programs

2016-2019 Trends

• Nevada has fewer pharmaceutical drugs on the streets but more counterfeit

pharmaceutical drugs

• Trafficking, sales and use of methamphetamine remains high
• Methamphetamine blended with opioid drugs
• Trafficking, sales and use of heroin remains stable
• Black market marijuana is robust
• Counterfeit marijuana products blended with opioids
• Cocaine trafficking and use has dramatically increased

Health and Human Services 5-Point Strategy To Combat the Opioid Crisis (Rx and Heroin)

https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html (Azar; 2017)

2018 National Safety Council

• 1. Mandating prescriber education
• 2. Implementing opioid prescribing

guidelines

• 3. Integrating PMP into clinical setting
• 4. Improving data collection/sharing
• 5. Treating opioid overdose
• 6. Increasing availability of opioid use

disorder treatment

Nevada’s MAT Treatment Infrastructure

• 192 providers are waivered to provide buprenorphine however, not all
• prescribe. For those who do prescribe, very few prescribe to their upper limit.
• 15 Opioid Treatment Programs within Clark, Washoe and Carson City
• Capacity remains available overall however, connection to high-quality,

integrated services remains a challenge

• Rural/Frontier communities have limited access
• Solutions include integrated treatment networks and increasing access within

primary care

Integrated Opioid Treatment and Recovery Centers

 ASAM Patient Placement  Mobile Recovery Outreach Teams  Peer Recovery Support  Screen, Assess, Stabilize, Hand-off

IOTRC

FQHCs Office Based Opioid Treatment Opioid Treatment Program/ Methadone Unit CCBHC Transitional Housing Withdrawal management 3.5 and 3.7 Substance Abuse Treatment Provider Inpatient and residential services

MAT Prescribers in Nevada, Fiscal Year 2018

MAT Prescribers in Nevada, Fiscal Year 2019

MAT Prescribers in Reno 2018

MAT Prescribers in Reno 2019

MAT Prescribers in Las Vegas 2018

MAT Prescribers in Las Vegas 2019

Overdose Education/ Naloxone Distribution

Distribute Naloxone to individuals with high-risk for overdose such as: Overdose survivors; Release/discharge from controlled environment following detox: jails, detox facilities, residential treatment centers, prison; Individuals who self-identify as at-risk: i.e. needle exchanges

Pharmacies to evaluate risk and dispense without a prescription Co-Prescribe for High Dosage/High Risk Pain Patients Promote the Good Samaritan Law

Overdose Education/ Naloxone Distribution

• 56 Law enforcement and first responder agencies across the state have been

supplied with 2,927 2-dose units of naloxone.

• 13 Distribution across Nevada sites have distributed over 3,516 units
• f Naloxone (including the IOTRCs)
• With the assistance of County Coalitions, Overdose Education

and Naloxone Distribution trainings have distributed 1,506 2-dose naloxone kits to members of the community statewide

• Over 277 reported opioid overdose reversals

Healthcare Utilization Costs

Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019* 8% 8% 5% 7%

Opioid-Related Hospital Data, State of Nevada Residents, 2010-2019*

In October 2015, ICD-10-CM codes were implemented. Previous to October 2015, ICD-9-CM codes were used for medical billing. Therefore, 2015 data consists of two distinct coding schemes, ICD-9-CM and ICD-10-CM respectively. Due to this change in coding schemes, hospital billing data from October 2015 forward may not be directly comparable to previous data. Emergency Room Encounters (ED) Emergency Room Crude Rates Percent Change Inpatient Admissions (IP) Inpatient Crude Rates Percent Change 161.2 174.7 183.3

• 1%

9% 21% 23% 25% 29% 194.0 242.7 293.7 180.9 6,530 7,165 292.8 317.2 8%

• 5%

0%

• 10%

Percent Change 2010-2018 97% 97% 5,695 4,543 196.5 159.8

Rates are per 100,000 State of Nevada Population.

1,515 2,433 7% 4,122 3,473 3,188 2,963 5,067 5,042 4,755 4,362 17% 147.2 126.3 117.1 109.5 9,616 8,744 8,675 7,032 5,517 215.4 239.9 253.8 7,495

Nevada’s Opioid Overdose Deaths

Opioid-Related Overdose Deaths, State of Nevada Residents, 2010-2018*

*Data for 2018 are preliminary.

Opioid Crisis is Evolving

• Nevada HIDTA has classified heroin, fentanyl, and methamphetamines as three
• f the top threats in 2018 (Nevada HIDTA, 2018)
• Fentanyl is 50-100 times more potent than heroin
• Can be mixed into drug supply (pills, heroin, methamphetamine)

2018 Overdose Deaths Clark Washoe

Synthetic opioids including fentanyl, related-deaths 56 13 Methamphetamine-related deaths 200 50 Heroin related-deaths 76 16

Nevada’s Opioid Overdose Deaths

Year Heroin Natural and Semi- Synthetic Methadone Synthetic Opioids Unspecified Narcotic 2010 19 298 98 39 45 2011 40 300 97 45 46 2012 42 301 69 25 40 2013 48 241 70 25 39 2014 61 216 63 31 37 2015 79 254 57 31 37 2016 82 228 52 49 28 2017 92 234 45 64 18 2018* 102 207 33 76 10 2019* 32 40 7 26 1

A person can be included in more than one drug group, and therefore the counts above are not mutually exclusive. *Data for 2018 and 2019 are preliminary. Data for 2019 includes Quarter 1 only.

Opioid-Related Overdose Deaths by Drug Category, State of Nevada Residents, 2010-2019*

Nevada’s Opioid and Benzodiazepine Overdose Deaths

Year Opioid-Related Overdose Deaths Crude Rates Percent Change Benzodiazepine Related Overdose Deaths Opioid and Benzodiazepine Related Overdose Deaths 2010 437 16.2 161 139 2011 460 16.9 5% 166 143 2012 437 15.9

• 6%

162 140 2013 396 14.1

• 11%

126 106 2014 365 12.8

• 9%

125 109 2015 409 14.1 10% 130 117 2016 393 13.3

• 6%

155 126 2017 401 13.4 1% 123 106 2018* 356 11.7

• 13%

139 112 2019* 92 22 19

• 27%

Rates are per 100,000 State of Nevada Population. *Data for 2018 and 2019 are preliminary. Data for 2019 includes Quarter 1 only.

• Roughly 85% of all benzodiazepine-related overdose deaths also involve opioids.
• Roughly 30% of all opioid-related overdose deaths also involve benzodiazepines.

Opioid-Related Overdose Deaths, State of Nevada Residents, 2010-2019*

Percent Change 2010-2018*

Each year:

Nevada Prescribing Patterns 2016

Opioid Painkiller Prescriptions per 100, 2011-2016

*definitions vary slightly between US and NV opioid prescriptions and populations used to calculate rates (Sources: Guy et al., 2017; Office of Public Health Informatics and Epidemiology; Prescription Monitoring Program)

NV (PMP) US NV (CDC Estimates)

Opioid Prescription Rates 2016

Opioid Painkiller Prescribing Rates Per 100, by County, 2016

County Rate Carson City 105.4 Churchill 106.8 Clark 84.3 Douglas 102.0 Elko 71.7 Esmeralda 72.5 Eureka 92.7 Humboldt 75.5 Lander 85.2 Lincoln 60.7 Lyon 130.0 Mineral 158.2 Nye 155.6 Pershing 69.5 Storey 146.9 Washoe 87.5 White Pine 99.9 Statewide 87.5

(Sources: Office of Public Health

Informatics and Epidemiology; Prescription Drug Monitoring Program)

Controlled Substance Abuse Prevention Act (AB474; 2017)

Prioritize patient safety and responsibility Preserve clinical decision-making Promote the patient-prescriber relationship Reduce the amount of inappropriate prescribing Prevent addiction to prescription drugs through monitoring and mitigating risk Enhance the quality of care for patients with acute and chronic pain Avoid legislation of the practice of medicine by establishing a standard of care

Implementation Challenges

• Pharmacist/Prescriber communication
• Confusion over interpretation of new provisions
• Misinformation to patients and prescribers
• Occupational Licensing Board regulations
• Comprehensive knowledge of pain management strategies
• Competencies across disciplines for interdisciplinary pain management
• Knowledge of resources for substance use disorder treatment

Nevada Prescribing Patterns 2018

76.4 87.9 74.4 78.1 83.5 82.3 74.9 52.0 100.3 98.9 91.1 90.1 85.4 80.7 73.0 80.9 81.3 78.1 75.6 70.6 66.5 58.5

20 40 60 80 100 2011 2012 2013 2014 2015 2016 2017 2018

Opioid Painkiller Prescriptions per 100 Population, 2011-2018

Nevada (PMP) NV (CDC Estimates) US (CDC Estimates)

*Definitions vary slightly between US and NV opioid prescriptions and populations used to calculate rates. MAT drugs are not included in the Nevada (PMP) rates. CDC Estimates for 2018 are not yet available. (Sources: US estimates: https://www.cdc.gov/drugoverdose/data/prescribing.html, NV estimates: https://www.cdc.gov/drugoverdose/maps/rxstate2017.html Nevada PMP: Prescription Drug Monitoring Program)

Opioid Prescription Rates 2018

Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations (HHS; 2018)

“The ongoing opioid crisis lies at the intersection of two substantial public health challenges — reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications.”

• - Pain Management and the Opioid Epidemic: Balancing Societal

and Individual Benefits and Risks of Prescription Opioid Use; National Academies of Sciences, Engineering, and Medicine, 2017.

AB 239 Overview

Use of patient PMP report

• Practitioner must review PMP report; and
• May prescribe CS, if the patient has already been issued an RX for the same CS, if deemed medically necessary

Prescribing guidelines for initial prescription for the treatment of acute pain

• Initial prescription may exceed 14-day supply or 90 MME if deemed medically necessary

Evaluation and risk assessment

• Medical history limited to the relevant medical history of the pts pain
• Completed if the prescription is more than a 30-day supply

Informed written consent

• Informed consent may but is not required to be in writing
• Provider shall document informed consent conversation and patient’s decision in medical record
• If written consent completed, include in pts record

AB 239 Overview

Exemption for hospice, palliative, oncology, and sickle cell except:

• PMP check
• Informed consent
• Valid prescription

Disciplinary action by regulatory agencies

• Allows another regulatory agency to seek disciplinary action for the same conduct if action is within its

statuary authority.

Factors to consider prior to prescribing any controlled substances (including non-pain meds)

• Requirement repealed

Course of Treatment definition

• Section 7 codifies definition

Acute Pain definition

• Section 10 codifies definition

273 245 210 112 68 14 302 265 208 82 63 13 225 275 167 79 51 17 134 287 114 71 38 12 50 100 150 200 250 300 350

2013 2014 2015 2016 2017 2018

Number of Potential "Doctor Shoppers" Per Quarter

Q1 Q2 Q3 Q4

• The total number of pts identified in the 24 quarters was 3,325.
• From the high of 302 pts (2013 Q2) to the low of 12 pts (2018 Q4), the volume of potential doctor

shoppers identified dropped by 96%.

121,298 172,499 348,866 493,980 737,188 134,488 190,383 353,709 501,404 726,146 151,880 216,830 394,956 471,636 695,614 163,986 347,185 432,590 530,572 642,519 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000

2014 2015 2016 2017 2018

Number of PMP Queries Per Quarter

Q1 Q2 Q3 Q4

• 30% increase in PMP queries from Q1 2014 compared to Q1 2015
• 51% increase in PMP queries from Q1 2015 compared to Q1 2016
• 29% increase in PMP queries from Q1 2016 compared to Q1 2017
• 33% increase in PMP queries from Q1 2017 compared to Q1 2018

Prescription Drug Monitoring Program Data, January 2017 – December 2018

39% decrease in the rate of opioid prescriptions per 100 Nevada residents.

• Opioid prescriptions with less than a 30 days supply decreased by 53%.
• Opioid prescriptions with greater than or equal to a 30 days supply and less than a 90

days supply decreased by 24%.

• Opioid prescriptions with greater than or equal to a 90 days supply decreased by 50%.

All Nevada counties observed a decrease in both the number of and rate of opioid prescriptions by month, with the decrease in rates ranging from 25% (Lincoln) to 56% (Humboldt).

• The number of individuals who were co-prescribed Opioid and Benzodiazepines during

the same month also decreased significantly, by 54% in Nevada overall.

DHHS Office of Analytics Data Source: Prescription Drug Monitoring Program (PDMP; 2018) http://dhhs.nv.gov/uploadedFiles/dhhsnvgov/content/Programs/Office_of_Analytics/Images/Nevada%20PDMP%20Surveillance,%20Pre%20and%20Post%20AB474%20(Jan%202017%20-%20Sep%202018)(1).pdf

98,923 91,540 102,183 91,778 98,71097,168 90,045 97,265 88,32889,139 83,342 78,640 58,733 49,744 52,676 49,68650,701 46,58346,750 52,931 47,28649,749 46,62746,440 51,066 47,964 50,83149,77751,379 45,656 98,982 93,211 104,514 94,109 100,760 99,115 92,267 96,349 86,74087,35985,26983,363 86,220 79,659 86,472 82,10084,677 79,30479,046 85,716 77,752 81,029 77,07074,79976,952 72,305 78,14976,228 80,942 73,389 816 690 848 779 773 782 788 726 752 731 670 754 591 511 574 494 511 449 437 465 395 419 399 408 304 253 264 285 285 255

20,000 40,000 60,000 80,000 100,000 120,000

Opioid Prescriptions With <30 Days Supply Opioid Prescriptions With >=30 and <90 Days Supply Opioid Prescriptions With >=90 Days Supply

Opioid Prescription Counts by Month January 2017 – June 2019

MAT drugs are not included.

Opioid Prescriptions For Both Less Than and Greater Than 30 Days and 90 Days, by Top 10 ICD-10 Group, 2019*

Prescriptions Diseases of the Nervous System, Pain, not elsewhere classified G89 24,417 Dorsalgia M54 22,611 Other joint disorder, not elsewhere classified M25 7,385 Dental Caries K02 6,490 Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders M51 5,729 Pain, unspecified R52 5,657 Diseases of pulp and periapical tissues K04 5,567 Spondylosis M47 4,720 Abdominal and pelvic pain R10 4,087 Other disorders of teeth and supporting structures K08 3,007 Prescriptions Dorsalgia M54 92,695 Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders M51 43,856 Spondylosis M47 41,104 Diseases of the Nervous System, Pain, not elsewhere classified G89 21,616 Other joint disorder, not elsewhere classified M25 15,748 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified M96 12,822 Cervical disc diorders M50 9,991 Other spondylopathies M48 7,270 Nontraumatic compartment syndrome M79 7,170 Osteoarthritis of knee M17 5,937 Prescriptions Dorsalgia M54 273 Diseases of the Nervous System, Pain, not elsewhere classified G89 90 Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders M51 64 Other joint disorder, not elsewhere classified M25 56 Nontraumatic compartment syndrome M79 51 Other and unspecified osteoarthritis M19 46 Spondylosis M47 42 Migraine G43 36 Polyosteoarthritis M15 33 Osteoarthritis of knee M17 26 Top 10 Diagnosis Groups Top 10 Diagnosis Groups < 30 Days Supply >= 30 but < 90 Days Supply Top 10 Diagnosis Groups >= 90 Days Supply 5,000 10,000 15,000 20,000 25,000 30,000

G89 M54 M25 K02 M51 R52 K04 M47 R10 K08

• 20,000

40,000 60,000 80,000 100,000

M54 M51 M47 G89 M25 M96 M50 M48 M79 M17

50 100 150 200 250 300

M54 G89 M51 M25 M79 M19 M47 G43 M15 M17

*Data for 2019 include quarters 1 and 2 only. MAT drugs are not included.

Number of Individuals Co-Prescribed Benzodiazepines and Opioids in the Same Month, January 2017 - June 2019

29,921 27,642 30,419 27,166 28,825 27,881 25,746 27,150 24,631 25,065 23,516 22,497 20,431 17,547 18,708 17,841 17,210 15,214 14,684 15,277 13,652 14,108 13,298 12,972 13,529 12,192 13,078 12,826 13,529 11,993 5,000 10,000

15,000 20,000 25,000 30,000 35,000

Keith Carter, HIDTA

keithc@lvmpd.com

Stephanie Woodard, Psy.D.

DHHS Senior Advisor on Behavioral Health swoodard@health.nv.gov

Yenh Long, Pharm.D., BCACP

Nevada State Board of Pharmacy ylong@pharmacy.nv.gov

Additional Information: www.Prescribe365.nv.gov

http://dhhs.nv.gov/Programs/Office_of_Analytics/

OFFICE_OF_ANALYTICS_-_DATA___REPORTS/

https://www.nvopioidresponse.org/

Contact Information