Vermonts Efforts to Confront the Opioid Crisis Mark A. Levine, MD - - PowerPoint PPT Presentation

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Vermonts Efforts to Confront the Opioid Crisis Mark A. Levine, MD - - PowerPoint PPT Presentation

Jan 18, 2024 148 likes •706 views

Vermonts Efforts to Confront the Opioid Crisis Mark A. Levine, MD Commissioner, VT Dept. of Health Beth Tanzman, Executive Director, VT Blueprint for Health April 11, 2018 Objectives Review Vermonts opioid crisis, both challenges

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April 11, 2018

Vermont’s Efforts to Confront the Opioid Crisis

Mark A. Levine, MD – Commissioner, VT Dept. of Health Beth Tanzman, Executive Director, VT Blueprint for Health

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Objectives

 Review Vermont’s opioid crisis, both challenges and successes

and provide context

 Understand characteristics of a high functioning state’s

response

 Discuss Vermont’s current and future response, the “four legged

stool”:

Vermont Department of Health 

Prevention

Intervention and Treatment

Enforcement

Recovery  Explore the successes of the Hub and Spoke model  Highlight where we are planning major initiatives

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Epidemiology

 21 million Americans have a substance use disorder,

 Comparable with the number of people diagnosed with diabetes  1.5 times the prevalence of all cancers combined.

 12.5 million Americans reported misusing prescription pain medications in

the past year

 1.9 Million dependent on pain relievers  517,000 dependent on heroin

 1-2 in 10 people with a substance use disorder currently receives

treatment.

Vermont Department of Health

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US Drug overdoses have overtaken car accidents, guns and HIV as cause of death and are leading cause under age 50

Vermont Department of Health

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Age Adjusted Overdose Deaths Involving Opioids by Type of Opioid United States, 1999-2016

Vermont Department of Health

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VT was statistically similar to the US rate in 2016: Age Adjusted Drug OD Death Rates

Vermont Department of Health

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New England - Any Drug Overdose Deaths

5 10 15 20 25 30 35 40

2010 2011 2012 2013 2014 2015 2016 Deaths per 100,000

Drug Overdose Deaths per 100,000 by State

Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont

Vermont Department of Health

Source: CDC/ NCHS

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Drug-Related Fatalities Involving Opioids

39 58 51 70 63 74 96 101

35 44 37 45 26 31 35 33 1 9 10 21 34 33 43 39 4 5 6 12 17 28 49 67

2010 2011 2012 2013 2014 2015 2016 2017 Total number of accidental and undetermined manner drug-related fatalities involving an opioid (categories not mutually exclusive) Total opioid Rx opioid Heroin Fentanyl

Source: Vermont Department of Health Vital Statistics System

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Nationally, over half of those who misused a prescription pain reliever got it from a friend or relative

Vermont Department of Health

Source: National Survey on Drug Use and Health, 2015

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Doctors are the most common source of opioids for most frequent nonmedical users

SOURCE: Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past- year nonmedical use: United States, 2008-2011. JAMA Internal Medicine. 2014

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SOURCE: JAMA 2011;305:1315-1321

The higher the morphine milligram equivalent, the higher the

  • verdose death hazard
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Past Year Pain Reliever Misuse by State: Percentages

Vermont Department of Health

Annual Averages Based on 2015 and 2016 NSDUH Surveys Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2015 and 2016

Past Year Pain Reliever Misuse Age 18-25 Vermont kids 12-17 have among the lowest rates of past year pain reliever misuse; those age 18-28 have among the highest Past Year Pain Reliever Misuse Age 12-17

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Past Year Heroin Use and Perceptions of Great Risk Aged 12 or Older, by State: Percentages

Vermont Department of Health

Annual Averages Based on 2015 and 2016 NSDUH Surveys Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2015 and 2016

Past Year Heroin Use Perception of Great Risk of Trying Heroin Once or Twice Vermonters have the highest use of heroin and amongst the lowest perception of great risk

  • f trying heroin once or twice.
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Major Factors Driving the Prescription Opioid and Heroin Epidemic

Vermont Department of Health

Source: NGA

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Hub & Spoke Evaluation: Participants

Vermont Department of Health

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Substances Used by Vermonters Ages 12+ by Substance Type

58 59 60 60 61 60 62 61 59 59 61 61 9 9 10 10 10 11 12 13 13 12 13 15 5 5 5 5 5 5 5 5 5 4* 3 0.8

Alcohol- Past 30 day Marijuana - Past 30 day Non-Medical Use of Pain Relievers - Past year Heroin - Past Year

Vermont Department of Health

Source: National Survey on Drug Use and Health, 2002-2015 Note: * delineates a significant drop since 2011/2012 (p<0.05)

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What is Vermont Doing?

Vermont Department of Health

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The National Safety Council Categorized Vermont as One of Four States Making Progress in Strengthening Laws and Regulations Aimed at Preventing Opioid Overdose

Areas Assessed:

➢

Mandatory Prescriber Education

➢

Opioid Prescribing Guidelines

➢

Eliminating Pill Mills (VT doesn’t have them but also doesn’t have legislation to eliminate/prevent them)

➢

Prescription Drug Monitoring Programs

➢

Increased Access to Naloxone

➢

Availability of Opioid Use Disorder Treatment In Place Not in Place

Vermont Department of Health

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Support at all levels

 Governor  State legislature  Collaboration

 state agencies and departments  state regions/cities  surrounding states  public and private insurers

 Federal funders

Vermont Department of Health

Elements of a High Functioning State Response to the Opioid Crisis

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Epidemiology

 Compile data from multiple data sources  Study variability by region  Maximize publicly available information  Include stakeholder input  Multi-state collaboration

Vermont Department of Health

Elements of a High Functioning State Response to the Opioid Crisis

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Elements of a High Functioning State Response to the Opioid Crisis Prevention

Pain management and prescribing practices:

Education at all levels (practicing clinicians, students, GME) Prescriber rules Prescription Drug Monitoring System

Vermont Department of Health

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The Problem

 As many as four out of five heroin users begin by abusing prescription drugs  Of those who abuse prescription opioids, seven out of 10 received these drugs

through methods of diversion

 Opioids are overprescribed. They are prescribed:  Too often  At too high a dose  For too long  Prescribers play a role in the supply and use of opioids in our and use of opioids in

communities.

Vermont Department of Health

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The more opioids prescribed during the first episode of opioid use, the greater the likelihood of continued opioid use

One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days’ supply* of the first opioid prescription — United States, 2006–2015 One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of prescriptions* in the first episode of opioid use — United States, 2006–2015

Source: Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.

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If you remember nothing else…

 First consider non-opioid and nonpharmacologic treatments  Upon first prescription, prescribers must:  discuss risks and safe storage and disposal  provide a patient education sheet, and  receive an informed consent for all first opioid prescriptions

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Pain Average Daily MME (allowing for tapering) Prescription TOTAL MME based on expected duration of pain Common average DAILY pill counts Commonly associated injuries, conditions and surgeries Minor pain No Opioids 0 total MME 0 hydrocodone 0 oxycodone 0 hydromorphone molar removal, sprains, non-specific low back pain, headaches, fibromyalgia, un-diagnosed dental pain Moderate pain 24 MME/day 0-3 days: 72 MME 1-5 days: 120 MME 4 hydrocodone 5mg or 3 oxycodone 5mg or 3 hydromorphone 2mg non-compound bone fractures, most soft tissue surgeries, most outpatient laparoscopic surgeries, shoulder arthroscopy Severe pain 32 MME/day 0-3 days: 96 MME 1-5 days: 160 MME 6 hydrocodone 5mg or 4 oxycodone 5mg or 4 hydromorphone 2mg many non-laparoscopic surgeries, maxillofacial surgery, total joint replacement, compound fracture repair Extreme Pain 50 MME/day 7 day MAX: 350 MME 10 hydrocodone 5mg or 6 oxycodone 5mg or 6 hydromorphone 2mg similar to the severe pain category but with complications or other special circumstances

MME Limits for First Prescription for Opioid Naïve Patients Ages 18+

For patients with severe pain and extreme circumstance, the provider can make a clinical judgement to prescribe up to 7 days so long as the reason is documented in the medical record.

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What is the Vermont Prescription Monitoring System?

 A statewide electronic database of controlled substance

prescriptions dispensed from Vermont-licensed pharmacies that became operational in January 2009

 A clinical tool to promote the appropriate use of controlled

substances and deter misuse, abuse, and diversion of controlled substances

 A surveillance tool used to monitor statewide prescribing,

dispensing, and use of controlled substances trends

Source: Vermont Prescription Monitoring System

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  • 1. Opioids are not first-line therapy
  • 2. Establish goals for pain and function
  • 3. Discuss risks and benefits
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Fewer Opioid Pain Relievers are Being Dispensed in Vermont - Total MME Opioid Analgesics per 100 Residents

73186 71543 73490 77095 68933 57019 50000 55000 60000 65000 70000 75000 80000 85000 90000 95000 100000

2012 2013 2014 2015 2016 2017

Data Source: VPMS Note: Prior to rescheduling tramadol was not reported to VPMS. On August 14, 2014 tramadol was changed from a schedule V to a schedule IV drug. There was a 26% decrease in dispensed opioids between 2015 and 2017, years that include tramadol.

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Elements of a High Functioning State Response to the Opioid Crisis

Prevention

 Public Level:

 Prevention messaging campaigns/education  School-based primary prevention programs  Build prevention infrastructure and expertise  Community mobilization  Education in and insurance coverage for evidence-based pharmacologic

and non-pharmacologic alternatives to opioids for pain management

 Collaboration across state agencies

Vermont Department of Health

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Communications & Marketing

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Other examples of prevention

 Regional Prevention Partnership Grants  ParentUpVT.org  Public service announcements, office posters  Academic detailing and Blueprint QI Opioid Prescribing  Vermont’s Most Dangerous Leftovers  School based prevention education, student assistance programs  Prevention consultants  Secondary prevention = VT Recovery Network  Community initiatives: Project VISION, CCOA and others

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

Prevention

 Public Level:

 Prevention messaging campaigns/education  School-based primary prevention programs  Build prevention infrastructure and expertise  Community mobilization  Education in and insurance coverage for evidence-based pharmacologic

and non-pharmacologic alternatives to opioids for pain management

 Collaboration across state agencies

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

 Harm-reduction strategies:

 Drug disposal options and systems; safe storage guidelines  Sharps collection and disposal programs  Naloxone distribution programs for first responders and the public  Naloxone standing order  Syringe services programs  Good Samaritan Law  Alternatives to incarceration for those at risk of entering the criminal justice

system due to drug use

Vermont Department of Health

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Naloxone

192 375 367 513 513 719 808 890 1063 1075 2393 1592 1585 1735 1583

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017

Number of rescue kits distributed to community members

8 31 29 46 69 82 141 98 115 121 93 82 51 97 97

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017

Reports of naloxone use in response to a perceived overdose incident

Source: Vermont Department of Health Naloxone Pilot Program

In July of 2016, VDH slowly began to switch to distributing naloxone in new packaging – demand for the new kits was high. Dose in the new kit is twice that of the

  • ld kit.
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Syringe Service Distribution

485,095 633,000 763,321 932,266 841,136 999,459 978,216 200,000 400,000 600,000 800,000 1,000,000 1,200,000

2010 2011 2012 2013 2014 2015 2016

Total number of syringes distributed by year

Vermont Department of Health

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Syringe Service Program Members

1,612 2,072 2,802 3,749 4,315 4,860 5,591

1,000 2,000 3,000 4,000 5,000 6,000

2010 2011 2012 2013 2014 2015 2016

Total number of syringe service program members by year

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

 Harm-reduction strategies:

 Drug disposal options and systems; safe storage guidelines  Sharps collection and disposal programs  Naloxone distribution programs for first responders and the public  Naloxone standing order  Syringe services programs  Good Samaritan Law  Alternatives to incarceration for those at risk of entering the criminal justice

system due to drug use

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

 Intervention and Treatment

 Include screening, intervention, and referral services in medical settings

(SBIRT)

 Widely available evidence-based Medication Assisted Treatment (MAT)

with methadone or buprenorphine with added:

 Counseling services  A Health Home model, with services to integrate and coordinate primary, acute,

behavioral health, and long-term services and supports

 Residential treatment, with or without MAT, where clinically indicated  Non-MAT outpatient treatment, where clinically indicated

Vermont Department of Health

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VT Prevention, Intervention, Treatment, Recovery Services

Specialty (Res)

Intensive Outpatient Treatment (IOP) Outpatient Treatment (OP), Hubs Screening, Brief Intervention, Referral for Treatment (SBIRT) Prevention Services

Highest Level Of Care Lowest Level Of Care Fewest Number

  • f

People Largest Number

  • f

People

Hospital Detoxification Physician (spoke) OP Services, Private Practitioner/DMH OP , DOC Medical Services AHS-SATC Screening

Recovery services are available at all service levels

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Effectiveness of Medication Assisted Treatment

 Several studies have clearly demonstrated MAT is effective across a

number of behavioral dimensions compared to placebo or psychological treatment alone:

 Reduced opioid use (including IVDU)  Increased engagement and retention in treatment  Reduced morbidity and mortality  Improved social functioning  Reduced criminal activity  Reduced transmission of infectious diseases

Vermont Department of Health

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Agency of Human Services 42 4/11/2018

Care for Opioid Use Disorder – the “Hub”

“HUB” A Hub is a specialty regional treatment center responsible for coordinating the care of individuals with complex opioid use disorder across the health and substance abuse treatment systems of care. All Medications are dispensed. A Hub is designed to do the following:

  • Provide comprehensive assessments and treatment protocols.
  • Provide medication (methadone, buprenorphine, and/or vivitrol) treatment and supports.
  • For clinically complex clients, initiate medication treatment and provide care for initial stabilization period.
  • Coordinate referral to ongoing care.
  • Provide specialty addictions consultation and support to ongoing care.
  • Provide ongoing coordination of care for clinically complex clients.

5 Programs Operate 9 Sites Across Vermont

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Agency of Human Services 43 4/11/2018

“SPOKE” A Spoke is the ongoing care system comprised of a prescribing MD, APRN, or PA and collaborating health and addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, and provide counseling, contingency management, and case management services. Spokes can be:

  • Primary care offices
  • Outpatient substance abuse treatment programs
  • Pain clinics
  • OB-GYN offices
  • Independent psychiatry practices

Spoke Teams include the prescribing provider and 1 FTE RN + 1FTE MH/SU Counselor for every 100 patients

80 different practices / programs are Spoke sites in Vermont

Care for Opioid Use Disorder – the “Spoke”

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Study Measurement Periods

Vermont Department of Health

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Self-Reported Changes in Opioid Use: T1 to T2

Measure In Treatment Out of Treatment

Change in Ave Days Used Percent Using at T2 Change in Ave Days Used Percent Using at T2

Days of Opioid Use

  • 96%

15% +12% 100% Days of Opioid Injection

  • 92%

11%

  • 1%

85%

Vermont Department of Health

Designates statistically significant change

Opioid use decreased substantially for people in both hubs and spokes. Those not in treatment continued to use at high levels.

“The hub was really good in a lot of ways because of the structure, the discipline. It makes you get back on track if you want to get back on track.” – Hub Patient “The main support is always they focus on your health and your wellbeing. They always try to make sure you’re

  • safe. That’s the number one thing, and then your substance abuse, to not using.” – Spoke Patient
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Self-Reported Changes in Functioning: T1 to T2

Measure In Treatment Group (n=80) Number of ED Visits

  • 89%

OD in the previous 90 days

  • 100%

Days of school or training +257% Days of work +8% Number of police stops or arrests

  • 90%

Days of illegal activity

  • 90%

Vermont Department of Health

Designates statistically significant change

There were significant decreases in the number of ED visits, arrests, and days of illegal activity. No study participants overdosed in the 90 days prior to the

  • interview. Days of school or training increased but there was not a significant

change in days of work.

The out of treatment group is excluded because there were no significant changes

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DVHA/Blueprint Cost Analysis

 “Impact of Medication-Assisted Treatment for Opioid Addiction

  • n Medicaid Expenditures and Health Services Utilization Rates

in Vermont” published in the Journal of Substance Abuse Treatment (August 2016)

 Highlights:

 Higher MAT treatment costs offset by lower non-opioid medical costs  MAT associated with lower utilization of non-opioid medical services  MAT suggested to be cost-effective service for individuals addicted to

  • pioids

 https://www.ncbi.nlm.nih.gov/pubmed/27296656

Vermont Department of Health

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Number of people receiving MAT in hubs and spokes vs number waiting for services over time

513 615 60 1000 2000 3000 4000 5000 6000 7000

Hub Spoke Number Waiting for Hub

Vermont Department of Health

Source: Hub Census and Waitlist, Medicaid Claims for Spokes

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Census Change - Hubs and Spokes

Vermont Department of Health

1500 2000 2500 3000 3500 4000

Jan-14 Jan-15 Jan-16 Jan-17 Est Jan 18

SPOKE CENSUS

1500 2000 2500 3000 3500 4000

Jan-14 Jan-15 Jan-16 Jan-17 Est Jan 18

HUB CENSUS

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Elements of a High Functioning State Response to the Opioid Crisis

 Intervention and Treatment

 Include screening, intervention, and referral services in medical settings

(SBIRT)

 Widely available evidence-based Medication Assisted Treatment (MAT)

with methadone or buprenorphine with added:

 Counseling services  A Health Home model, with services to integrate and coordinate primary, acute,

behavioral health, and long-term services and supports

 Residential treatment, with or without MAT, where clinically indicated  Non-MAT outpatient treatment, where clinically indicated

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

 Intervention and Treatment, cont’d.

Peer recovery coach availability in ED and hospitals

Access to MAT in correctional facilities

Specialty treatment services for pregnant women and their infants

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

Recovery

 Strong statewide network of recovery centers with access to peer

recovery coaches

 Availability of and equal access to stable recovery housing  Opportunities to grow the state’s workforce by employing individuals

in recovery

Vermont Department of Health

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Elements of a High Functioning State Response to the Opioid Crisis

Recovery

 Strong statewide network of recovery centers with access to peer

recovery coaches

 Availability of and equal access to stable recovery housing  Opportunities to grow the state’s workforce by employing individuals

in recovery

Vermont Department of Health

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System of Care Enhancement: Workforce

 Strengthen the workforce & increase number of qualified

providers

 Support workers in pursing path to certification/licensure  Increase number of federally “waivered” prescribers trained to

provide office-based opioid use disorder treatment

 Expand opportunities for credentialed clinicians to access training

Vermont Department of Health