[PPT] - Welcome & Introduction Charles Papp, M.D. President, PowerPoint Presentation

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Welcome & Introduction

Charles Papp, M.D. President, Lexington Medical Society Lexington Medical Society

Opioid Symposium: Perspectives, Connections, & Strategies for Action October 16, 2019

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LMS Opioid Symposium

Thank you to our sponsors

Beverly Games & Jesse Lawler Karen McIntyre and Angela Coleman John DeWeese & Mike Soares

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Lexington Medical Society

Opioid Symposium: Perspectives, Connections, & Strategies for Action

The opioid crisis has grown to the point where it penetrates all walks of life, all occupations, and is found in every

neighborhood. The Opioid Symposium will provide

physicians with tools and resources they can use in their practices. Objectives: ▪ Inform physicians & community leaders on: ▪ The background & scope of the opioid crisis in Lexington ▪ Perspectives from organizations on the front lines of the crisis ▪ Identify ways physicians and community leaders can connect patients and community members to support

LMS Opioid Symposium

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LMS Opioid Symposium

For CME credit:

Sign-in
Turn in a survey

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LMS Opioid Symposium

P A N E L

Catherine Hines SUD Education and Outreach Coordinator Findhelpnowky.org Mark Jorrisch, M.D., DFASAM Immediate Past President Kentucky Society of Addiction Medicine Michelle Lofwall, M.D., DFASAM Professor of Behavioral Science & Psychiatry and Bell Alcohol & Addictions Chair at U.K. Center on Drug & Alcohol Research. Lou Anna Red Corn Fayette Commonwealth’s Attorney Kraig Humbaugh, M.D., MPH Commissioner of Health Lexington-Fayette County Health Department Ryan Stanton, M.D. Emergency Medicine physician with Central Emergency Physicians at Baptist Health Lexington & Chief Medical contributor for WKYT TV Chad Traylor Battalion Chief, EMS Danesh Mazloomdoost, M.D. Medical Director, Wellward Regenerative Medicine Tuyen Tran, M.D., MBA LMS Executive Board Chair Owner and CEO, 2nd Chance Andrea James Community Response Strategist for Mayor Linda Gorton Charles Papp, M.D. President, LMS

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LMS Opioid Symposium

5 4 3 2 1

Sponsors Dinner Buffet P A N E L Community Resources

1. Health Department 2. Chrysalis House 3. Find Help Now KY.org 4. KORE (KY Opioid Response Effort) 5. Additional literature

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LMS Opioid Symposium

▪ Please save your questions for the panel at the end ▪ We have distributed question cards at each table ▪ Make sure you have signed in and complete the survey in order to receive the CME credit ▪ Approved for a maximum of 2.5 hours of AMA PRA Category 1 CME credits. ▪ Approved for a maximum of 2.5 hours HB1 credits

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Mayor’s Vision

Andrea James Special Projects Coordinator, Mayor’s Office LMS Opioid Symposium

Andrea James serves as Community Response Strategist for Mayor Linda

Gorton. Her emphasis is on the opioid crisis and its impact on the City of
Lexington. She served on Lexington’s city council 2007-2011 representing the

First District and has the distinct honor of being the first black woman to serve as an elected city council member in Lexington. Andrea has worked in local government, philanthropy and various medical administrative roles. Outside of her work with Mayor Gorton, she is co-owner of S & A Strategies, a consulting firm specializing in intentional inclusion and equity.

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Personal Reflections

Melissa Combs LMS Opioid Symposium

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Setting the Stage of the Opioid Crisis

Tuyen Tran, M.D., MBA LMS Opioid Symposium

Tuyen Tran, M.D. emigrated from South Vietnam after the war. He completed his undergraduate in biology/chemistry and medical school at the University of Missouri – Kansas City in a six-year

program. He is currently boarded in internal medicine and

addiction medicine.

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OPIOID EPIDEMIC KENTUCKY UPDATE

Tuyen T. Tran, MD, MBA

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DISCLOSURES – NONE

Tuyen T. Tran, MD, MBA
Partner and CEO
2nd Chance – Addiction Treatment Center

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OUTLINE

How did we get here?
Updates – Kentucky data
Impact of opioid epidemic

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Chronic Pain – 20th Century

We still do not quite understand chronic pain
AND we still do not have great treatment options for chronic

pain

Physicians OVERPRESCRIBE opioids
But, physicians also overprescribe diagnostic evaluations, labs,

imaging studies and antibiotics!!

Physicians do not want to miss a diagnosis which could harm

patients

Physicians do not want patients to experience pain

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Factors Contributing to the Opioid Epidemic

Physician overprescribing of opioids

– Leftover pills are the problem

“pill mills”

– Dr. David Proctor, the “Godfather of Pill Mills” – 1992-2001, America’s first “pill mill” in South Shore, KY

Cultural change regarding opioids and pain

– Too many patients are suffering unnecessarily because of inadequate pain management – Physicians needed education to dispel the concern for addiction – Insurances were not reimbursing for non-pharmacologic modalities for the treatment of chronic pain

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Cultural Changes Regarding Pain and Opioids

1980 NEJM one paragraph letter: Jane Porter and Hershel Jick, MD

– Retrospective review of 11,882 hospitalized patients who received narcotics – Four patients were found to have “well documented addiction”

1986 PAIN Doctors Kathleen Foley and Russel Portenoy

– Iatrogenic risk was low in 38 chronic non-cancer pain patients treated with

pioids
1995 Dr. James Campbell, president of American Pain Society,

promoted “Pain is the Fifth Vital Sign”

1998 VHA incorporated pain as the “fifth vital sign”
JCAHO (Joint Commission on Accreditation of Healthcare

Organizations) embraced the “Pain is the Fifth Vital Sign”

JCAHO issued standards requiring the use of a pain scale and

treatment of pain, especially with opioids

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Regulatory and Cultural Pressures

JCAHO referred to pain management as a patient’s rights issue

– Inferred sanctions if pain was inadequately controlled

1985 Press Ganey, a survey of patients’ hospital experiences

– Collection of patient data was necessary for improvement – Distinction between patient satisfaction and quality of care BLURRED

CMS (Centers for Medicare and Medicaid Services) developed

the value-based purchasing program

– Patient experience collected via HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) – “Did hospital staff do everything they could to help you with your pain?”

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Pressure on Physicians to Prescribe Opioids

Reimbursement to hospitals were tied to patient satisfaction
Hospitals coerced physicians (via withholding payment or

bonuses)

– CMS only required 300 surveys in a 12-month period – Only a small number of patients actually completed the surveys – A single poor survey could significantly impact whether the hospital achieved the required 90% percentile goal of patient satisfaction – Thus, every patient must be satisfied!

When patients requested/demanded opioid pain medications,

physicians were often compelled to satisfy the patients, despite their reservations about the need for opioids

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Kentucky Update - 2017

Drug overdose deaths in the Commonwealth ranked 4th highest

among the 50 states

1,565 Kentuckians died from a drug overdose (UP 11.5% from 2016)

– Largest demographic: 35-44 y/o – Heroin: 22% of OD (DOWN from 34% in 2016) – Fentanyl: 52% of OD (UP from 47% in 2016)

Largest increase in OD were in counties: Jefferson, Fayette,

Campbell, and Kenton

Largest decrease in OD were in counties: Madison, Bell, Knox,

Breathitt, and Scott

Perspectives: 2017

– 782 died in traffic accidents – 263 people were murdered

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Impact on Families and Children

Stress
Financial strains
Employment
Relationships
Co-dependency
Criminal justice system
Neonatal Abstinence Syndrome (NAS)

– CDC: KY had 3rd highest rate of opioid use at delivery among the 50 states

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Impact on Criminal Justice System

Offenders imprisoned for drug offenses

– 2000: 30% – 2009: 38%

Offenders sent to state prison for drug possession doubled from

2012 to 2016

Offenders imprisoned for drug trafficking

– 2012: 1,525 – 2016: 1,916 (25% increase)

Offenders jailed for drug possession

– 2012: 911 – 2016: 1836

Current cost to incarcerate a state inmate in KY: $18,406 per year
About 4,500 additional inmates (drug offenses) costed KY in 2016:

$82M

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Impact on the Workforce

Alan Krueger, Princeton economist, published 2016

– Strong link between RISING opioid prescriptions and DECLINING workforce participation rates (percentage of people employed or looking for work) – Half of men aged 25-54 who are not in the workforce take pain medication daily

2018 Research by Federal Reserve Bank of Cleveland

– Workforce participation rate was 4.6% LESS on average in counties with high rates of opioid prescribing

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Impact on Kentucky Workforce

2017 report by Kentucky Chamber of Commerce

– Kentucky had one of the lowest workforce participation rates in the country – Contributing factors:

High levels of disability
High levels of poverty
High levels of incarceration
Low education attainment
High levels of substance abuse
Kentucky employers cannot fill available jobs!

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Community Collaboration

Engage business leaders to discuss the opioid problem
Increase public education
Support efforts to hire people in recovery
Reclassify drug possession as a misdemeanor

– Reduce number of offenders going to jail for drug possession – Remove barriers to people in recovery from acquiring employment

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Heal Pain

Danesh Mazloomdoost, M.D. LMS Opioid Symposium

Danesh Mazloomdoost, MD is a Johns Hopkins & MD Anderson trained anesthesiologist, pain, and regenerative specialist. As an international speaker, author, and advocate for reform in pain management, Dr. Danesh consults with private and governmental organizations to develop protocols for pain that minimize opioid dependency, improve patient satisfaction and health outcomes. His new book, Fifty Shades of Pain: How to Cheat on your Surgeon with a Drugfree Affair has become an Amazon international best- seller in ten categories. He is now the Medical Director of Wellward Regenerative Medicine in Lexington Kentucky, the flagship for a new and sustainable approach to managing pain while avoiding drugs or surgery.

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HEAL pain

Danesh Mazloomdoost, MD Medical Director

Info@Wellwardmed.com

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Healing Beyond Medicine

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Healing Beyond Medicine

Acute Opioid Response

Rx - Opioid Time Pain Intensity Opioid effect on pain score Pain Generator Rx - Opioid Rx - Opioid Rebound Mauermann et al. Anesthesiology 2016 Feb;124(2):453-63

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Healing Beyond Medicine

6) Acute pain < 3days

Acute pain course < 3 days

24-72hrs 1-3 wks Resolve

> 7 days rare and often reflects

undiagnosed pathology

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Healing Beyond Medicine

Onset of Dependency

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.

Long-term use > 1 year

6% for >1 day
13.5% >8 days
29.9% >31 days

(7% of all Rx) Chronic Use risk spikes at 3 days

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Healing Beyond Medicine

Rx - Opioid Rx - Opioid Rx - Opioid

Time Pain Intensity

Chronic Opioid Response

Rx - Opioid

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Healing Beyond Medicine

Physiologic Pain Opioid Pain

Opioids

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walk on a broken leg

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6.5% become

pioid

dependent

Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. Published online April 12, 2017

Opioid-naïve patients undergoing surgery

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Healing Beyond Medicine

Messenger age Pain ≠ Disease Pain = Disease

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Healing Beyond Medicine

Dissecting Pain

PAIN Nerves Tissue

Injury

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Healing Beyond Medicine

Biomedica l (Regenerat ive) Kinesthe tic

(Function al Movemen ts) Psycholog ical (Behavior & Lifestyle)

Primary Care for Pain

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heal

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H E A L

ear nvision lleviate everage

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Healing Beyond Medicine

Pain Mapping

Hearing…

precision accuracy

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Healing Beyond Medicine

Envisioning…

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Healing Beyond Medicine

Alleviating…

Desensitization
Somatic Blocks
Autonomic Blocks
Neuroablation
Neural Modulation
Dorsal Column
Peripheral Nerve

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Healing Beyond Medicine

Leverage…

Cellular Healing

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Healing Beyond Medicine

Healing Cycle

Injury Inflammat ion Proliferati

n

Regeneratio n Rehabilita tion

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Healing Beyond Medicine

Injury

Järvinen et al Muscles, Ligaments and Tendons Journal 2013; 3 (4): 337-345

Injury

Inflamma tion Proliferat ion Regeneratio n Rehabilita tion

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Healing Beyond Medicine

Inflammation

Injury

Inflammatio n

Proliferat ion Regeneratio n Rehabilita tion

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Healing Beyond Medicine

Proliferation

Injury Inflamma tion

Proliferatio n

Regeneratio n Rehabilita tion

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Healing Beyond Medicine

Regeneration

Injury Inflamma tion Proliferat ion

Regenera tion

Rehabilita tion

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Healing Beyond Medicine

Rehabilitation

Injury Inflamma tion Proliferat ion Regenerat ion Rehabilitati

n

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Healing Beyond Medicine

Cellular Healing

Leverage…

Prolotherapy: Chemical-induction
Autologous growth factors: PRP, PL, PR
Allogenic growth factors:

placental & amniotic derivatives

Xenogenic tissue matrices
Mesenchymal Cells, SVF, CFUs

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Healing Beyond Medicine

Regenerative Outcomes: WHO WILL HEAL FASTER?

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ptimize

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Healing Beyond Medicine

info@wellward.com

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First Responders

Battalion Chief Chad Traylor LMS Opioid Symposium

Joined the Lexington Fire Department in 2003. Began career assigned to a fire engine and after completing paramedic training transferred to an ambulance. Throughout the years has held the assignments of a Company Officer, Hazardous Material Team Leader, District Major, Special Operations Commander and is currently the EMS Battalion Chief.

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Emergency Physician

Ryan Stanton, M.D. LMS Opioid Symposium

EM doc with Central Emergency Physicians at Baptist Health Lexington. Chief Medical contributor for WKYT TV and producer of “The Doc Is In”, the weekly heath segment airing in 6 TV markets throughout the

southeast. Medical Director for Lexington Fire/EMS and on track traveling

physician for the AMR/NASCAR Safety Team. National Spokesperson for the American College of Emergency Physicians and producer of the ACEP Frontline Podcast. Dr. Stanton has been speaking around the country regarding opioids for the past 10+ years and is currently involved with the KHA SOS initiative.

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Health Department

Kraig Humbaugh, M.D. LMS Opioid Symposium

As Commissioner of Health, Kraig E. Humbaugh, MD, MPH is the chief executive officer and medical director for the Lexington-Fayette County Health Department. He is a board-certified pediatrician who has practiced medicine for over twenty-five years in community, academic and public health settings. Dr. Humbaugh earned his undergraduate degree from Vanderbilt University, studied as a Fulbright Scholar at the University of Otago in New Zealand, and received his medical degree from Yale University. He holds a Master of Public Health degree from Johns Hopkins University.

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Reducing Harm Among People who Inject Drugs

Lexington Medical Society’s Opioid Symposium October 16, 2019

Kraig E. Humbaugh, MD, MPH Commissioner, Lexington-Fayette County Health Department kraig.humbaugh@ky.gov

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WHAT IS A NEEDLE EXCHANGE?

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▪ A public health program designed to reduce the negative health consequences of injection drug use: “Meeting people where they are.”

▪ Provides new, sterile needles and syringes ▪ Provides safe disposal site for contaminated needles and syringes

▪ Needle exchange programs are proven to reduce the spread of HIV, hepatitis C, and

ther blood-borne infections, without leading to

increased drug use in communities. They can decrease needle stick injuries. ▪ Under Kentucky law, only health departments can operate needle exchange programs.

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Logistics of Lexington’s Exchange

When: Mondays 1-4 PM; Wednesdays 3-6:30 PM;

Fridays 11 AM-4 PM

Where: Lexington-Fayette Co HD: 650 Newtown

Pike

What: Free, anonymous, modified needs–based

needle exchange

Uses trained health department employees who
ften have other “day jobs” at the health

department

Cost to agency: about $500,000 per year.

Compare to lifetime cost of one new case of HIV (>$350,000)or cost of treating one case of hepatitis C ($30,000-$50,000)

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MONTHLY VISITS TO NEEDLE EXCHANGE PROGRAM: 28,228 Visits by 5,059 Clients

September 4, 2015 – September 6, 2019

67 82% 42% 39% 24% 43% 39% 39% 21% 25% 17% 31% 38% 34% 32% 28% 21% 24% 23% 23% 21% 19% 15% 13% 14% 14% 13% 16% 16% 13% 15% 13% 15% 11% 13% 12%9% 8% 9%12%9%10% 10%8% 8% 7%10%7% 7% 18% 58% 61% 76% 57% 61% 61% 79% 75% 83% 69% 62% 66% 68% 72% 79% 76% 77% 77% 79% 81% 85% 87% 86% 86% 87% 84% 84% 87% 85% 87% 85% 89% 87% 88% 91% 92% 91% 88% 91% 90% 90% 92% 92% 93% 90% 93% 93% 200 400 600 800 1000 1200 1400 Sep '15 Oct Nov Dec Jan '16 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan '17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan '18 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan '19 Feb Mar Apr May Jun July Aug First Visit Repeat Visit

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AGE DISTRIBUTION OF NEEDLE EXCHANGE PROGRAM CLIENTS (n=5024)

September 4, 2015 – September 6, 2019

68

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REPORTED DRUG OF CURRENT USE AT CLIENT ENCOUNTER

September 4, 2015 – September 6, 2019

73% 21% 2% 2% 2%

Heroin Methamphetamine Suboxone Oxycodone Cocaine

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SELF-REPORTED FIRST TIME CLIENT PARTICIPATION IN TREATMENT/RECOVERY PROGRAMS

March 3, 2018 – September 6, 2019

PAST PARTICIPATION IN A TREATMENT/RECOVERY PROGRAM (n =1515) NUMBER OF TIMES IN TREATMENT/RECOVERY PROGRAM (n=988)

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TOTAL NEEDLES RECEIVED & DISTRIBUTED, LFCHD NEEDLE EXCHANGE PROGRAM

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Total Number of Needles Received September 4, 2015-September 6, 2019 Total Number of Needles Distributed September 4, 2015-September 6, 2019 943,506 1,152,346 Ratio of needles received to needles distributed: 0.82 : 1

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Other Harm Reduction Strategies

Needle exchange is one part of a

comprehensive harm reduction plan.

Additional services offered on-site at the

exchange through partnerships with community partners, under a confidential, medical/provider model:

rapid HIV and hepatitis C testing (with AVOL)
hepatitis A and B vaccination
referrals to counseling and treatment (with

LFUCG, New Vista, Chrysalis House)- over 200

naloxone training and distribution (with LFUCG)

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Naloxone Distribution

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As of September 6, 2019, 2976 naloxone kits have

been distributed for use in the community setting.

Training is done by health department nurses and

takes about 15-20 minutes total.

Participants are taught how to recognize an
verdose, how to administer naloxone nasal spray

and to call emergency medical services

More trainings, including community events, are

planned.

A media campaign is being developed to

encourage people to carry and use naloxone when needed.

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Kraig Humbaugh, MD, MPH

Commissioner of Health Lexington-Fayette County Health Department

kraig.humbaugh@ky.gov

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County Prosecutor

Lou Anna Red Corn Fayette Commonwealth’s Attorney LMS Opioid Symposium

Lou Anna Red Corn was appointed Fayette Commonwealth’s Attorney in 2016, and elected to the position in 2018. She has been a prosecutor in the office since 1987. Lou Anna serves the state’s prosecutors as treasurer and Best Practice Committee Co-Chair of the Commonwealth Attorney’s Association, she is the current state’s representative to the National District Attorneys Association and the nation’s prosecutor representative on the National Children’s Alliance Board of Directors, the organization that accredits the country’s Children Advocacy Centers.

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HEAL Program

Michelle Lofwall, M.D. LMS Opioid Symposium

Michelle Lofwall MD is a Professor of Behavioural Science and Psychiatry and the Bell Alcohol and Addictions Chair at the University of Kentucky Center on Drug and Alcohol Research. She is the medical director of the First Bridge

utpatient opioid use disorder (OUD) treatment clinic that provides

comprehensive care to patients discharging from the emergency room and inpatient medical/surgical services. Her clinical research has been funded by the National Institutes of Health and industry with a focus on OUD. She was as an expert panel member on SAMHSA’s newly published Substance Treatment Improvement Protocol (TIP 63) for Medication Treatment of OUD, a board member of the American Society of Addiction Medicine, an invited speaker to the National Academy of Medicine and recipient of several medical student teaching and mentorship awards.

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NIH HEALING COMMUNITIES STUDY UPDATE MICHELLE LOFWALL, MD PROFESSOR COLLEGE OF MEDICINE CENTER ON DRUG AND ALCOHOL RESEARCH

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SUBSTANCE USE RESEARCH AT UK

The University of Kentucky has established 6 research priority

areas, which grew out of a 2014 Board of Trustees Retreat. These highlight a focus on research where:

The needs of Kentuckians and the Commonwealth are most

pressing; and,

The University can continue to compete successfully for

external research support. (see: https://www.research.uky.edu/research-priorities-initiative)

The UK Substance Use Priority Research Area (SUPRA) mission

is to prevent and reduce the burden of substance use disorder (SUD) through conducting and translating multidisciplinary and innovative research to inform clinical services, training, public health practice and policy.

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A partnership with the National Institutes of Health (NIH), the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) The funding announcement required specific evidence-based prevention and treatment interventions, including: prevention efforts related to opioid overdose; screening and assessment of

pioid misuse and OUD; linkages and engagement in treatment;

use of medications to treat OUD; and ongoing recovery support

services. Integrated evidence-based interventions will be delivered

in multiple settings and are required to include healthcare, behavioral health, and justice settings.

THE HEALING COMMUNITIES STUDY

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The primary aim is to develop an evidence-based integrated strategy to reduce opioid-related overdose deaths by 40% in three years in at least 15 highly affected communities by:

➢ Increasing distribution of naloxone (Narcan) ➢ Increasing the number

f

individuals receiving medication treatment for opioid use disorder ➢ Increasing retention of people in treatment beyond 6 months ➢ Increasing the number of people receiving recovery support services

THE HEALING COMMUNITIES STUDY

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THE HEALING COMMUNITIES STUDY

$87 million was awarded to the University of Kentucky (one of four states to receive the award). Massachusetts, New York, and Ohio were also awarded. Our project is being conducted in partnership with numerous federal, state, community, public health, criminal justice, behavioral health, and health care partners. HEALing Communities Study – Kentucky is led by Dr. Sharon Walsh, Director of the UK Center on Drug and Alcohol Research

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HCS Sites

Massachusetts New York Ohio Kentucky

Rural Urban

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COUNTY SELECTION FOR HEALING COMMUNITIES: KENTUCKY

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Design

120 48 35 28 25 19 16

Counties in Kentucky Counties with ≥ 25 opioid overdose deaths per 100,000 residents in 2017 Counties without ‘suppressed data’ (i.e., ≥ 5 opioid

verdose deaths)

Counties with justice infrastructure (i.e., jails) Counties with treatment infrastructure (i.e., ≥ 1 provider licensed to prescribe medication) Counties with public health infrastructure (i.e., SSP) Counties not already involved in a major UK intervention project

The served area encompasses over 1.8 million people (approximately 41% of the state’s population).

48 counties with > 25 opioid overdose deaths per 100k in 2017

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HEALING COMMUNITIES: KENTUCKY

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Projects were required to target at least 15 counties or cities highly affected by overdose, defined as:

➢ A rate of 25 opioid related overdose deaths per 100,000 persons or higher in the past year ➢ The Kentucky HEALing Communities counties had an average rate of 45.7 opioid-related overdose deaths per 100,000. ➢ Combined total of at least 150 opioid-related overdose fatalities ➢ The Kentucky HEALing Communities counties had a total

764 opioid-related overdose deaths in 2017.

➢ 30% of the counties/cities must be rural

➢ 44% of Kentucky HEALing Communities counties are rural

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HEALING COMMUNITIES: KENTUCKY

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Expand access to overdose- reversing naloxone Link people leaving jail and on probation/parole to treatment and naloxone Link clients of harm reduction programs to treatment and naloxone Reduce high-risk prescribing and increase safe disposal of medications Reduce barriers to medication treatment and improve retention in care Provide peer support services to help people through recovery

The project will be guided by local community coalitions and the following potential strategies:

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➢ Every county in the project will receive a “Care Team” ➢ Communities will be engaged in a communication campaign to reduce stigma and improve awareness of services

THE HEALING COMMUNITIES STUDY: KENTUCKY CARE TEAMS

Community Coordinator Syringe Service Program Prevention Specialist Treatment Care Navigator Jail Care Navigator Probation and Parole Prevention Specialist Local coalition (ASAP Board)

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Train-the-trainer overdose education and naloxone training for local health department staff, local pharmacists, and first responders Rigorous evaluation of what works and what does not work could inform intervention rollout for other parts of the state Detailed cost-effectiveness analysis will be shared with policy-makers at the state and local level so that they can consider it in future program funding decisions

THE HEALING COMMUNITIES STUDY: KENTUCKY SUSTAINABILITY

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Where to Get Help, MAT, Psychotherapy

Mark Jorrisch, M.D., DFASAM LMS Opioid Symposium

Immediate Past President of KYSAM, distinguished Fellow of ABAM, Board Certified Internal Medicine and Addiction Medicine, practice at BHG Lexington, an OTP offering both methadone and buprenorphine, and at the MORE Center in Louisville, an OTP offering methadone.

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Mark Jorrisch MD DFASAM Methadone Maintenance Treatment

No disclosures

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Heroin and the Reward Pathway

Heroin

(di-acetyl- morphine)

very

lipophilic

rapidly

crosses the blood brain barrier in the Reward Pathway

This is the reason heroin is preferred

ver

morphine by injection

pioid

users Withdrawal Normal Euphoria Chronic use Initial use Tolerance & Physical Dependence

Alford DP. http://www.bumc.bu.edu/care/

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Development of Substance Use Disorders Involves Multiple Factors

Substance Use Disorder Biology (Genes/Development) Environment Drug / Alcohol Use Brain Mechanisms

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Reward & Reinforcement is…

 Ventral

Tegmental Area (VTA)

 Nucleus

Accumbens with projections to Prefrontal Cortex

 Dopaminer

gic system

...in part controlle d by mu receptor s in the Reward Pathway

Leshner AI. Hosp Pract. 1996

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Longitudinal Trends in Recovery

36% 66% 86% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months (n=157; OR=1.0) 1 to 3 years (n=138; OR=3.4) 3 to 5 years (n=59; OR=11.2) 5+ years (n=96; OR=11.2) % Sustaining Abstinence Through Year 8 Duration of Abstinence at Year 7

After 5 years <15% relapse It takes a year of abstinence before <50% relapse

Dennis ML et al. Eval. Rev. 2007

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Medically Supervised Withdrawal Management (“Detox”)

Low rates of retention in treatment High rates of relapse post-treatment < 50% abstinent at 6 months < 15% abstinent at 12 months Increased rates of overdose due to decreased tolerance

O’Connor PG. JAMA. 2005. Mattick RP, Hall WD. Lancet. 1996. Stimmel B et al. JAMA. 1977.

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Medications to Treat Opioid Use Disorders

Goals

Alleviate signs/symptoms of physical withdrawal Opioid receptor blockade Diminish and alleviate drug craving Normalize and stabilize perturbed brain neurochemistry

Options

Opioid Antagonist

 Naltrexone (full antagonist)

Opioid Agonist

 Methadone (full agonist)  Buprenorphine (partial agonist)

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Naltrexone

Mu-opioid receptor antagonist

Not a controlled substance, no special prescribing restrictions

Patients physically dependent must be opioid free for a minimum of 7-10 days before treatment

Also FDA approved for the treatment of alcohol use disorders

Oral naltrexone (generic and brand

Revia)

 Well tolerated  Duration of action 24-48 hours  FDA approved 1984

IM injection extended- release naltrexone (Vivitrol)

 IM injection (w/ customized needle)

nce/month

 FDA approved 2010

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Naltrexone Summary

Benefits

Good for patients who do not want opioid agonist therapy No risk of diversion (not a controlled substance) No risk of overdose by drug itself Can be administered in any setting (office-based or OTP) Long-acting formulation Treats both opioid use disorder and alcohol use disorder

Limitations

Difficulty starting—must be fully withdrawn from opioid; > short- acting (6 days); long-acting opioids (7-10 days) Not recommended for pregnant

women. Pregnant women who are

physically dependent on opioids should receive treatment using methadone or buprenorphine Not suitable for patients with severe liver disease

Loss of tolerance to opioids increases the risk of overdose if relapse occurs Kampman, K. et al. (2015). The ASAM National Practice Guideline

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Methadone Hydrochloride

Full opioid agonist

Oral: 80-90% bioavailability liquid, tablet, and disket formulations

Duration of action

 24-36 hours to treat OUD  6-8 hours to treat pain

Proper dosing for OUD

 20-40 mg for acute withdrawal  > 80 mg for craving, “opioid blockade”

Can be administered parenterally (IV, SQ or IM)

 at 80% of the total daily oral dose administered in a divided dose every 12

hours (e.g., 40 mg by mouth every day = 16 mg IV every 12 hours)

Mercadante S. (2013) Handbook of Methadone Prescribing and Buprenorphine Therapy.

SLIDE 99

Methadone Maintenance in OTP

Highly structured Methadone dosing

Daily nursing assessment Weekly individual and/or group counseling Random supervised drug testing Psychiatric services Medical services Observed daily → “Take

homes” based on stability and time in treatment. Max: 27 take homes. Varies by state, county and individual clinics

SLIDE 100

Methadone Summary: Benefits

Increases overall survival Increases treatment retention Decreases illicit

pioid use

Decreases hepatitis and HIV seroconversion Decreases criminal activity Increases employment Improves birth

utcomes

Joseph et al. Mt Sinai J Med. 2000;67:347-364.

SLIDE 101

Methadone Summary: Limitations

Highly regulated: Narcotic Addict Treatment Act 1974 Created methadone clinics (Opioid Treatment Programs) Separate system not involving primary care or pharmacies

Limited access Inconvenient Mixes stable and unstable patients Lack of privacy No ability to “graduate” from program

Stigma: “Methadone is substituting one drug for another…I don’t believe in methadone”

SLIDE 102

Buprenorphine

Semi-synthetic analogue of thebaine

Approved by the FDA in 2002 as Schedule III — up to 5 refills

High receptor affinity

Slow dissociation

Ceiling effect for respiratory depression

Partial Mu-

pioid agonist , k

antagonist

SLIDE 103

Buprenorphine Efficacy: Summary

Studies (RCT) show buprenorphine (16-24 mg) more effective than placebo and equally effective to moderate doses (80 mg) of methadone on primary outcomes of:

 Retention in treatment  Abstinence from illicit opioid use  Decreased opioid craving  Decreased mortality  Improved occupational stability  Improved psychosocial outcomes

Johnson et al. NEJM 2000; Fudala PJ et al. NEJM 2003; Kakko J et al. Lancet 2003; Sordo L et al. BMJ 2017; Mattick RP et al. Conchrane Syst Rev 2014; Parran TV et al. Drug Alcohol Depend 2010

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There Remains Limited Access to Evidence-Based, Long-Term, Life-Sustaining Treatment with Medications for Patients Seeking OUD Treatment

SLIDE 105

Guidelines for the Behavioral Treatment as Part

f Medication-Based OUD Treatment (WHO 2009)

Psychological support should be

ffered routinely in association

medications for OUD Treatment services should aim to offer onsite, integrated, comprehensive psychosocial support to every patient

While patients should be offered psychosocial support, they should not be denied medication should they refuse such support, but encouragement to utilize psychosocial support should be continued

SLIDE 106

12 Step Oriented Treatment Self-help Groups Group Therapy Supportive Psychotherapy Cognitive Behavioral Contingency Management Cue Exposure Psychodynamic Network Therapy Community-Based Model Couple or Family Vocational Training Motivational Enhancement Relapse Prevention

106

Treatment Interventions

SLIDE 107

PCSS Pill counts

Pharmacy collaboration State prescription monitoring reports Urine drug tests Psychosocial & behavioral treatments Appropriate prescribing practices Therapeutic doctor-patient relationship

Many Layers of SUD Practice

107

SLIDE 108

Find Help Now KY.org

Catherine Hines Coordinator, KY Injury Prevention & Research Center at U.K. LMS Opioid Symposium

Catherine Hines is the Education and Outreach Coordinator for findhelpnowky.org, Kentucky Injury Prevention and Research Center’s treatment locator website. She holds her BA in Classical Studies from Centre

College. Catherine currently works with treatment facilities to ensure they

update essential information onto the website as needed. She also reaches

ut to new treatment centers in an attempt to onboard them to the website.

She works with the FindHelpNowKY team in the process of managing interest from other states which may implement this website for their own

communities. Since her interest lies in education, she is working on

researching and making connections with Universities and Colleges throughout the state in an attempt to educate them on the website and its use.

SLIDE 109 Catherine Hines, SUD Education and Outreach Coordinator Kentucky Injury Prevention and Research Center Bona fide agent of the Kentucky Department for Public Health University of Kentucky, College of Public Health

A Valuable Tool in the Fight Against Addiction

SLIDE 110

FindHelpNowKy.org

 Project Overview  Application in Healthcare Setting  Website Demonstration  State of Treatment in KY

SLIDE 111

FindHelpNowKy.org What is it?

 Dynamic near-real-time substance use disorder

(SUD) treatment locator and information repository

 Valuable tool for healthcare professionals, public

safety officials, and the general public

 Unprecedented inter-cabinet collaboration in

response to the opioid and overdose crisis in KY

 Resource for research and insights into the state of

SUD treatment in KY

SLIDE 112

FindHelpNowKy.org Project Overview

 Funded for 2016-2019 by Centers for Disease

Control and Prevention (CDC)

 National Center for Injury Prevention and Control

Prevention for States (PfS) grant

 Funded for 2019-2022 by Centers for Disease

Control and Prevention (CDC)

 Overdose Data to Action (OD2A) Grant

SLIDE 113

Partnerships

SLIDE 114

Project Team

Terry Bunn, PhD KIPRC Director Dana Quesinberry, JD Principle Investigator Jodie Weber Program Manager Catherine Hines SUD Education and Outreach Coordinator Tyler Jennings Technical and Marketing Coordinator

SLIDE 115

FindHelpNowKY.org Development Goals

 Quick and easy search to facilitate rapid access to

treatment

 Near-real-time information on availability of treatment slots  Advanced filters to meet specific needs  Resource library, including one pagers on SUD topics  1-833-8KY-HELP helpline prominently displayed  Dynamic analytics to facilitate research and track state of

treatment in KY

 Broad compatibility

SLIDE 116

FindHelpNowKY.org Development Outputs

 Fully designed and tested front- and back-end environments  Management interface to track provider engagement  28 one-page documents on variety of SUD topics  Informational brochures  Pocket cards  Instructional videos for public and providers  Healthcare provider-patient SUD communication guide

SLIDE 117

FindHelpNowKY.org Treatment Provider Stats

 Currently indexing over 600 KY treatment facilities  Approximately 90% of licensed AODE/BHSO treatment facilities  Over 50 MAT DATA Waivered physicians on board  Approximately 10% of MAT Data Waivered physicians in the state  Difficult to reach and engage population  Over 100 data points captured for each facility  From total treatment slots to tobacco use and gender-based bed

assignment policies

SLIDE 118

Let’s Take a Tour:

SLIDE 119

FindHelpNowKY.org Application in Healthcare

 Massive reduction in time to find available treatment options  Get a list of facilities with openings and sorted by distance in about 20

seconds. More specific results in a little over a minute.

 Quickly find and share resources with patients or their loved ones  Use filters and text search to rapidly narrow list of resources  Match unique patient needs to treatment providers  Filters for demographic info, comorbidity, additional services, payment methods, etc…  Enhances SBIRT or related processes  Easily fits in to SBIRT intervention and referral steps  Healthcare provider communication guide created by KIPRC augments SBIRT with stages of change model

SLIDE 120

FindHelpNowKY.org Stats to Date

 Since soft launch in Jan 15, 2018:  608 total facilities (~90% of licensed treatment facilities; ~10% of MAT providers in state)  Over 242,000 unique visitors, 353,000 total visits, 606,000 total pageviews  Roughly 50% male, 50% female  Over 115,000 searches (41% concerned family, 35% healthcare professional, 24% individual)  Providers have logged in over 8,000 times to view or update their profiles  Currently working on bringing the FindHelpNowKY platform to four additional states

SLIDE 121

FindHelpNowKY.org Average Visitor

 First time visitor to the site  Male  Aged 25-44  From Jefferson County or surrounding area  Searching on behalf of a friend or family member  Looking for residential/inpatient treatment that accepts a form of Medicaid  MAT is a close second  Spends about 6 and a half minutes searching for facilities

SLIDE 122

FindHelpNowKY.org State of Treatment

Source: Data gathered 06/21/2019 from FindHelpNowKY.org Source: Data gathered 06/21/2019 from FindHelpNowKY.org and Google Analytics 327 190 201 58 93 12 100 200 300 400 OP IOP MAT Detox Reside… Inpatie… Treatment Options by Treatment Type Total Facilities

SLIDE 123

Contact Info

Catherine Hines info@FindHelpNowKY .org 1-800-204-3223

SLIDE 124

LMS Opioid Symposium

P A N E L

Catherine Hines SUD Education and Outreach Coordinator Findhelpnowky.org Mark Jorrisch, M.D., DFASAM Immediate Past President Kentucky Society of Addiction Medicine Michelle Lofwall, M.D., DFASAM Professor of Behavioral Science & Psychiatry and Bell Alcohol & Addictions Chair at U.K. Center on Drug & Alcohol Research. Lou Anna Red Corn Fayette Commonwealth’s Attorney Kraig Humbaugh, M.D., MPH Commissioner of Health Lexington-Fayette County Health Department Ryan Stanton, M.D. Emergency Medicine physician with Central Emergency Physicians at Baptist Health Lexington & Chief Medical contributor for WKYT TV Chad Traylor Battalion Chief, EMS Danesh Mazloomdoost, M.D. Medical Director, Wellward Regenerative Medicine Tuyen Tran, M.D., MBA LMS Executive Board Chair Owner and CEO, 2nd Chance Andrea James Community Response Strategist for Mayor Linda Gorton Charles Papp, M.D. President, LMS

SLIDE 125

LMS Dinner Meeting November 13, 2019 The Opioid Crisis Insights from the Pharmaceutical Trial

Guest Speaker Danesh Mazloomdoost, MD

When: November 13, 2019

6:00pm Social
6:30pm Dinner
7:00pm Program
8:00pm Complete

Where: Hilary J. Boone Center, University of Kentucky, 500 Rose Street Cost: Free to members & their spouses $30 for non-member guests

Go to lexingtondoctors.org to register and for more information

Note: Date Change To Wednesday

Nov. 13, 2019

SLIDE 126

Lexington Medical Society

Opioid Symposium: Perspectives, Connections, & Strategies for Action

LMS Opioid Symposium