The Opioid Epidemic Open Door Integrated Care
Daren Wu, M.D.
Jacob Samander, M.D.
Lynn Gonzalez, L.C.S.W.
October 31, 2016
Open Door’s History
• Founded in the basement of a church in
1972
• Originally staffed by volunteer Doctors and
Nurses
• Gained Federally Qualified Health Center
recognition and Section 330 funding
Open Door Family Medical Centers
•
•
•
•
5 Primary Care Sites
7 School Based Health Centers
Family Medicine Residency program
Dental Residency program
Patients by Age and Sex
(Under age 1)
(1-19)
(20-49)
(50-64)
(65 & Up)
After childhood, we see a considerable difference between the number of men and women that we see.
We attribute this trend to the high number of women that we see during child-bearing age.
Insurance Coverage of
Open Door Patients
4%
8%
Uninsured
7%
Medicaid
50%
32%
CHIP
Medicare
Private
Open Door Family Medical Centers
At the end of 2015, we had:
• Over 100 Medical, Behavioral, and Dental
clinicians providing care to…
• 50,000 patients in…
• 265,000 visits
Clinician Breakdown
• Medical clinicians (MDs, DOs, NPs, Pas, CNMs)
47 FTEs
• Behavioral Health clinicians (LCSWs, LMSWs)
22 FTEs
• Psychiatrists
1.3 FTEs
Addiction – Over 24 Million Adults
12+ live with a SUD
• Only 10% or 1/10 individuals sought or received
treatment for their addiction
• Opioid overdose is now the #1 cause of
preventable death
– higher than car accidents
– higher than gun violence
• We are 3 times more likely to die of an opioid
overdose than a car accident and most car
accidents are substance related
NSUDH (National Survey on Drug Use and Health), 2013
“Addiction is
Irrational”
• Primary, chronic brain
disease characterized by
compulsive drug seeking
and use despite harmful
consequences
• Involves cycles of relapse and remission
• 40-60% genetic
• Without treatment addiction is progressive and
can result in disability or premature death
American Society of Addiction Medicine. April 12, 2011. www.asam.org
NIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction
Childhood Dreams and Aspirations
Dopamine D2 Receptors are Lower in
Addiction
Drugabuse.gov
Withdrawal
Normal
Euphoria
Natural History of Opioid Use Disorder
Acute use
Slide courtesy of Dan Alford, 2012
Tolerance &Physical
Dependence
Chronic use
Functional Recovery Takes Time
Normal
1 month post- detox
Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001
14 months
Addiction is Similar to Heart Disease
Decreased Heart Metabolism in
Coronary Artery Disease
Decreased Brain Metabolism in
Addiction
High
Healthy Heart
NIDA
Diseased Heart
Healthy Brain
Diseased Brain
For more severely addicted individuals…
Course of SUD and achievement of stable
recovery can take a long time
Addiction
Onset
Help
Seeking
4-5 years
Opportunity
for earlier
detection
through
screening in
non-specialty
settings like
primary
care/ED
Selfinitiated
cessation
attempts
www.mghcme.org
Full Sustained
Remission (1
year abstinent)
8 years
4-5
Treatment
episodes/
mutualhelp
Relapse Risk
drops below
15%
5 years
Continuing
care/
mutualhelp
60% of
individuals
with addiction
will achieve
full sustained
remission
(White, 2013)
Relapse Requires Increased Support
• We label patients as “not ready” or “noncompliant”
• We ask them to seek a higher level of care on their own,
when most ill
• We refer them for “higher level of care” – yet many of those
programs are not evidence based, and are essentially lower
level of care
• What would we do if a cancer survivor had a lymphoma
recurrence after years of remission?
Sources of Pain Medications
Medication Rx Numbers - 2013
• PERCOCET (Hydrocodone/
Acetaminophen) is the #1 most prescribed
medication in the USA
• XANAX is the #1 most prescribed
Psychiatric medication in the USA
IMS Institute for Healthcare Informatics, 2013
Medication is an Effective Tool
• “Access to medication – assisted
treatment can mean [the] difference
between life or death.”
Michael Botticelli, October 23, 2014
Director, White House Office of National Drug
Control Policy
Medication Treatment
• “MAT” = Medication PLUS counseling and behavioral
therapies
• “Opioid Agonist Therapy,” medication, or treatment
preferred
–
–
–
–
–
–
–
–
–
Reduces drug use
Reduces the risk of infectious disease transmission
Reduces criminal activity
Reduces the risk of overdose
Reduces death
Increases treatment retention
Improves social functioning
Cost-effective
Safe
Overdoses Symptomatic of Untreated
Disease
“A key driver of the overdose epidemic Is underlying
substance-use disorder. Consequently, expanding access
to addiction-treatment services is an essential
component of a comprehensive response.”
• 50% of Addiction treatment centers offer
medication
• <38% of eligible patients are offered medications
• <5% of physicians are waivered to prescribe
buprenorphine
Buprenorphine
Major Paradigm Shift: DATA 2000
• Partial agonist – antagonist
• Sublingual
• Higher affinity for the mu opioid
receptor compared to full agonists
• Slow to dissociate
• Will displace full agonists from the
receptor with decreased opioid
effect  precipitated withdrawal
• Relieves cravings without producing euphoria or
dangerous side effects of other opioids
• Naloxone to deter IV use, not active sublingually
Open Door and Controlled Medications
2014: Controlled meds policy - updated
2015: Tableau database - viewable
controlled medication prescribing data
2016: March 16th - new CDC guideline
2016: March 27th - eRX mandate
Concerning Statistics
• More than 40 people die every day from
opioid overdoses
• 1:32 patients with MME > 200 die from an
overdose
• 4.3 million Americans using prescription
opioids for non-medical use
Enter the Cavalry!
On March 18th, 2016 the CDC released a new guideline for
opioid prescribing. Expansion in funding from Feds and
NYS is coming as well.
Together, these aim to:
• Reinforce indications for opioid use
• Specify cautionary dosing levels for opioids (MME)
• Improve clinician training for medication treatment and
weaning strategies
• Create more outpatient treatment facilities (including
buprenorphine certification)
The Most Important Intervention
Change prescribing behavior!
• Indication – when to initiate
• Duration – how long to Rx
• Patient selection – dependency/addiction
risks
• Patient monitoring (urine tox, contracts,
prescription monitoring programs)
• Weaning suggestions
Are prescription opioids indicated?
…post-surgically?
…after a dental procedure?
…for an acute back pain, headache, sprain,
or fracture presentation in the ED?
Outpatient family doctors write more opioid
prescriptions than any other specialty
Clinician Comfort with Opioid Rx Varies
• Physician training in residency for psychiatric
conditions, including substance use and
chemical dependency as well as opioid and
benzodiazepine use, is very uneven
• PAs and NPs generally have even less
training than the physicians—and therefore
less comfort and familiarity—with pain
conditions and the use of these medications
Unequal Burden
• 14 Open Door clinicians account for more
than 90% of opioid Rx prescribing
• These are also the clinicians with the
largest and most complex patient panels
• Open Door is concerned about the burnout
risk for these clinicians
Organizational In-Service
• Series of Grand Rounds to elevate clinician
familiarity and comfort level with the topics of:
–
–
–
–
Depression
Substance use and addiction (including Opioids)
Anxiety disorders (touching on Benzodiazepines)
Sleep disorders (touching on sleep hypnotics)
Group Conversations (a.k.a. Grand Rounds)
1:1 Collegial Clinician Support
What the #!&$
were you
thinking!?
This is the last
time I ask you
for help…
Jay
Daren
Case Management = Team Work
• Case conferencing around complex cases
– BH, Patient Advocate, PCP, Psychiatry
• Frequent BHIS and LCSW touchpoints and visits
• Ad hoc (but documented!) consultations tracked in
eCW Telephone Encounters, including treatment
recommendations and modifications
Case Study: NK
• 65 yo gentleman with:
–
–
–
–
–
–
–
–
–
–
Hep C
HTN
DM
Lumbar disc herniation
Spinal stenosis
Cirrhosis
h/o IVDA
h/o alcohol abuse
Anxiety disorder
Depression
Case Study: NK
• More than 20 years of chronic opioid and
benzodiazepine use, and as of a few
months ago he was on:
– 40 mg of hydromorphone daily
– 2 mg of clonazepam daily
Case Study: NK
• Psychiatry and Family Medicine co-management
• With weekly follow-up visits (either with
psychiatry, LCSW) and also with family
physician PCP, the team was able to help NK
get off entirely from clonazepam use within 4
weeks, and reduced his hydromorphone use
from 40 mg/day to 8 mg/day over the space of 5
weeks
And if at first you don’t succeed…
Try and try again!
Because over time the
impact can be huge!
From Awareness  Action!
Improved Opioid Prescribing 2015 - 2016
Substance use
Grand Rounds
Opioid Addiction
Grand Rounds
From Awareness  Action!
Improved SSRI prescribing 2015-2016
Steep Drop-off in Rx written…
Integrated Behavioral Health
Approach To Treatment
Primary
Care
BHIS
Patient
Psychiatrist
Behavioral
Therapist
Chronic Pain Affects Many
Dimensions of Patient’s Life
Psychological
Anxiety/
Depression
• Function
• Activities
of daily living
• Sleep/rest
Physical
Borneman T, et al. Oncol Nurs Forum. 2003; 30:997-1005
Anger/
Fear
• Relationships
• Ability to
show affection/
sexual function
• Isolation
Social
Assess Risk to Determine
Treatment Options
Pain and Psychiatric Disorder
• Recent estimates suggest that pain and depressive
disorder co-occur 30-60% of the time
• Anxiety disorders may be present 35% of the time
among persons with chronic pain
• Pain and PTSD co-occur; 20-34% of persons with
chronic pain meet criteria for PTSD; chronic pain is
present in 45-87% of persons with PTSD
• Pain is present in 37-61% of patients seeking substance
use disorders treatment
• Pain undermines effective treatment for depression,
anxiety disorders, PTSD, and substance use disorders
Robert D. Kerns, Ph.D. Director, Pain Research, Informatics, medical comorbidities, and
Education (PRIME) Center, VA Connecticut Healthcare System
“…what is at stake is that patient’s very
ability “to become a full person without
the shadow of always needing
something.”
-Friedman
http://www.nytimes.com/2016/10/16/magazine/generation-adderall-addiction.html?_r=0
Personal Narrative
“When I think about the day I was injured I
can feel the pain in my back flare up right
where I was hurt. My whole day seems to
be spent waiting for the time to take my
next pain pill. I know they don’t help that
much, but it’s all I have.”
36 year old male veteran with chronic back and leg pain
Robert D. Kerns, Ph.D. Director, Pain Research, Informatics, medical comorbidities, and
Education (PRIME) Center, VA Connecticut Healthcare System
Goals of Psychological Pain
Treatment
Chronic Pain Treatment Resources
Summary
1. Have (or adopt) guidelines
2. Actually follow the guidelines chosen
3. Support your clinicians
– Increase knowledge and comfort level with pain
conditions and treatment parameters
– Team-based care
– Case conferencing
4. Support the patient(s) – which includes limit setting,
following care plans, and not enabling pathologies
5. Repeat steps 2-4, constantly
Questions???
[email protected]
[email protected]
[email protected]
Naloxone: Preventing
Opioid Overdose in the
Community
Sharon Stancliff, MD
Medical Director
Harm Reduction Coalition
DISCLOSURES
• No conflicts to disclose
• The off-label use of injectable naloxone
intranasally will be discussed
LEARNING OBJECTIVES:
.
Discuss the epidemiology of opioid overdose
including recent shifts to heroin and illicit
fentanyl.
Identify how to avoid, recognize, and act on
opioid overdoses
Discuss the role and safety of prescribing and
distributing naloxone in the community.
Deaths related to prescription opioids and heroin
drug poisoning United States, 2000–2014
*Age-Adjusted Rates
Compton et al. NEJM 2016;374:154-63
Opioid-Related Deaths in NYS—20032014
March 24, 2016
Opioid-Related Deaths in NYS—2003-2014
1400
1319
1254
1227
2012
2013
1165
1200
1000
922
924
895
2008
2009
2010
851
739
800
579
600
421
341
400
200
0
2003
2004
2005
2006
2007
2011
2014
LIMITATIONS OF THESE DATA
• Known underreporting
• Data only as good as certificates
• Variability among counties in thoroughness of tox screens and reporting
Fentanyl
Related²
22%
Other
Opioid³
47%
Fentanyl &
Heroin
Related4
9%
Heroin
Related¹
22%
Other Opioid³
26%
Fentanyl &
Heroin
Related4
19%
¹ No fentanyl; possible other drugs involved
² No heroin; possible other drugs involved
³ No fentanyl or Heroin; possible other drugs involved
4 Possible other drugs involved
Fentanyl
Related²
43%
Heroin
Related¹
12%
Rate of unintentional drug poisoning deaths by
drug type, NYC 2000-2014*
(Drugs not mutually exclusive)
Age-Adjusted Rate per 100,000
12
Opioids
10
Opioid
Analgesics
8
6
4
2
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
*Data for 2014 are preliminary and subject to change.
Source: New York City Office of the Chief Medical Examiner &
New York City Department of Health and Mental Hygiene 2000-2014*
Fentanyl & Overdose Deaths
• Fentanyl was relatively uncommon in overdose in NYC with
fewer than 3% of deaths involving fentanyl in the past ten
years
• Of the 886 drug overdose deaths in 2015, 136 (15%) involved
fentanyl
Strategies to address overdose
•
•
•
•
•
•
•
Increase access to naloxone
Good Samaritan laws
Prescription monitoring programs
Prescription drug take back events
Safe opioid prescribing education
Supervised injection facilities
Expansion of opioid agonist treatment
Opioid Overdose
Opioid
Overdose
Characteristics
Opioid
receptors are in
the
respiratory
center in the
medulla
White JM, Irvine RJ. Mechanism of fatal opioid overdose.
Addiction. 1999 Jul;94(7):961-72.
• Reduced
sensitivity to
changes in O2 and
CO2 outside of
normal ranges
• Decreased tidal
volume and
respiratory
frequency
• Respiratory
failure
and death due to
hypoventilation
Opioid Overdose
Toxidrome
Develops Over
Minutes to Hours
• Decreased
respiratory rate,
• Unresponsiveness
• Blue/gray lips and
nails
Naloxone
• Reverses overdose and prevents fatalities
• Mu opioid receptor antagonist
– No clinical effect in absence of opioid agonists
– Displaces opioids from receptors
• Takes effect in 2-5 minutes
– May cause withdrawal
– Lasts for 30-90 minutes (longer for newest formulation)
• Hepatic metabolism; renal excretion
Formulations
Risk Factors for Opioid Overdose
• Reduced Tolerance
• Mixing Drugs
• Using Alone
• Changes in the Drug
(risk factor for fatal OD) Supply
• Illness
• History of previous
• Depression
overdose
• Unstable housing
• Doses ≥100 mg
morphine-equivalent
doses
Lowered tolerance
• Tolerance- repeated use of a substance may lead to
the need for increased amounts to product the
same effect
• Abstinence decreases tolerance increasing overdose
risk
–
–
–
–
Incarceration
Hospitalization
Drug treatment/ Detox/ Therapeutic communities
Sporadic patterns of drug use
• Sporer 2007, Binswanger 2013
15
Overdose deaths in New York City involve
multiple drugs: 2014
• 97% of overdose deaths involved more than one
substance. Approximately eight in ten (79%)
overdose deaths involved an opioid.
• •Benzodiazepines were found in 54% of overdose
deaths involving opioid analgesics, 41% of deaths
involving heroin, and 55% of deaths involving
methadone
NYCDOHMH 2015
Context of Opioid Overdose
• The majority of heroin overdoses are witnessed
(gives an opportunity for intervention)
• The circumstances of prescription drug overdoses
are less well characterized
• Fear of police may prevent calling 911
• Witnesses may try ineffectual things
– Myths and lack of proper training
– Abandonment not uncommon
Tracy 2005
17
NYS Public Health Law
2006
• Allows the medical provider to provide naloxone for
secondary administration.
• Naloxone must be prescribed by MD, DO, PA, or NP either in
person Offers some liability protection
• 2014 amendments to the PHL made naloxone
accessible through non-patient specific
prescriptions (“standing order”)
Training Essentials
• What does naloxone do?
• Overdose recognition
– Sternal rub/grind
• Action
– Call EMS and administer naloxone
• Recovery position
Training recommendations in most
settings
• Risk factors for overdose/overdose death
– Loss of tolerance
– Mixing drugs
– Using alone
• Good Samaritan Law
• Hands on practice with device
• Resuscitation
– Rescue breathing and/or
– Chest compressions
Shake and shout
Sternal rub/grind
Call 9-1-1 AND Naloxone
22
• Tell the 9-1-1 dispatcher, “I think
someone has overdosed.”
– Give the address and location
AND
• Give the Naloxone
• DO FIRST, whichever is closer at hand
Give naloxone
Give naloxone
Rescue breathing or full CPR
or chest compressions
Second dose
26
If the person does not
respond in 2-3 minutes, give
a second dose of naloxone.
Do not wait more than 5
minutes to give a second
dose.
After You Give Naloxone
• Explain what happened. Tell them not to take any more
drugs because that could cause another overdose.
• Naloxone wears off in 30 to 90 minutes. Stay with the
person until they go to the hospital, or until the
naloxone wears off, to make sure they do not overdose
again.
• If you do not seek medical care, stay with the person for
at least 3 hours
• Call 911 if the person is not OK when they wake up or
take them to the emergency Room yourself.
• When the ambulance arrives, tell them that naloxone
has been given.
27
New York State’s Good Samaritan law
Sept. 18, 2011
• Protects:
– Individual who experience an overdose
and
– Person who summons EMS (calls 9-1-1)
• Prevents prosecution for:
–
–
–
–
–
Possession of up to 8 Oz of a controlled substance
Alcohol (for underage drinkers)
marijuana (any amount)
Paraphernalia offenses
Sharing of drugs (in NY sharing can be a “sales” offense)
28
Evaluations of Overdose Education and
Naloxone Distribution Programs
• Piper et al. Subst Use Misuse 2008: 43; 858-70.
• Doe-Simkins et al. Am J Public Health 2009: 99: 788-791.
• Enteen et al. J Urban Health 2010:87: 931-41.
• Bennett et al. J Urban Health. 2011: 88; 1020-30.
• Walley et al. JSAT 2013; 44:241-7. (Methadone and detox programs)
Feasibility
Increased
knowledge
and skills
• Green et al. Addiction 2008: 103;979-89.
• Tobin et al. Int J Drug Policy 2009: 20; 131-6.
• Wagner et al. Int J Drug Policy 2010: 21: 186-93.
No increase in use,
increase in drug
treatment
• Seal et al. J Urban Health 2005:82:303-11.
• Doe-Simkins et al. BMC Public Health 2014 14:297.
Reduction in
overdose in
communities
• Maxwell et al. J Addict Dis 2006:25; 89-96.
• Evans et al. Am J Epidemiol 2012; 174: 302-8.
• Walley et al. BMJ 2013; 346: f174.
Cost-effective
$438 (best)
$14,000 (worst )
per quality-adjusted
life year gained
Coffin and Sullivan. Ann Intern
Med. 2013 Jan 1;158(1):1-9.
Massachusetts
• Massachusetts compared interrupted time series of
towns by enrollment in Opioid Education and
Naloxone Distribution programs
• 2912 kits distributed
• 327 rescues, 87% by drug users; 98% effective
EMS revived the other 3
Walley et al BMJ 2013
Community results
Fatal opioid OD rates compared no implementation
• Program enrollment 1-100 per 100k population
(ARR: 0.73)
• Program enrollment >100 per 100,000 (ARR:0.54)
No differences were found in nonfatal opioid OD rates.
Walley et al BMJ 2013
Increase drug use?
Of the 325 with 2 points of data on drug use:
• No increase in reported use of opioids, alcohol,
cocaine or number of substances used
• Significant increase in reported use of
benzodiazepines:
– 30% increased use
– 23% decreased use
Doe-Simkins et al BMC Public Health 2014
New York City Longitudinal Cohort
Study
• Recruitment at trainings provided by 6 syringe
exchange programs and 2 methadone programs
June 2013 - January 2014
• Interviewed at baseline, 3 months, 6 months and 12
months
• 398 were recruited, 80% of whom reported use of
an opioid, 33% reported injection in the past year
• 342 (86%) were interviewed at least once in the
follow up period (Sept 2013 - Dec 2014)
Huxley-Reicher Z. 2016
Results
• 135 (39%) study participants witnessed at least one opioid
overdose, with 63% of these participants witnessing more
than one overdose
• A total of 338 overdoses were observed
• Naloxone was administered by the study participant in 189
(57%) of cases and by another lay person in an additional 57
(17%) of cases
• In 12 months, of 398 trained individuals, 87 used naloxone
and 2 had their naloxone used on them (22 reversals for
every 100 trained)
Huxley-Reicher Z. 2016
NYC Department of Health and Mental Hygiene
Implementation in NY State
Over 300 sites have registered to distribute free kits provided
by the New York State Department of Health
• Syringe exchange/syringe access providers
• Drug treatment providers
• Agencies focused on homeless populations
• Law enforcement agencies
• Local health departments
• Educational institutions
• School Districts
• NYS Department of Corrections and Community Supervision
• Primary care
• HIV services
September 2016
Special Focuses
Expanding
Nearly 300 programs currently active or recently registered – 185 in
Community Program 2014 & 2015;
Basic Life Support
Permissible scope of practice now includes IN naloxone.
Law enforcement
Frequently first on the scene of an OD.
Firefighters
As with police, firefighters are often first on the scene
Corrections
Pilot in 10 State prison facilities being expanded to others
School Settings
Began in August 2015 with changes in Public Health and Education laws
Pharmacy
Pharmacy dispensing pursuant to standing orders
is now underway. Patient specific prescriptions as
well
Pharmacy
Pharmacies are now carrying naloxone
• Dispense with a patient specific order
• Dispense per an non-patient specific (standing) order
– Work with registered opioid overdose programs
– Register as an opioid prevention program
Pharmacy
1,983 pharmacies throughout New York State able to
dispense naloxone under standing orders including
111 independents
• 713 in New York City
• 1,270 in rest of state
All chains with greater than 20 stores are required to
dispense
Insurance coverage
• All Medicaid plans must cover at least one formulation of
naloxone for people at risk of overdose
• Medicaid Fee for Service covers naloxone under standing
orders at pharmacies- awaiting word from Managed Care
• No information on private insurance
• If a patient cannot afford the naloxone and/or co-pay, they
should be directed to listing of NYS Opioid Overdose
Prevention Programs
Opioid-Related ED Visits by Receipt of Naloxone
Prescription Among Primary Care Patients with
Chronic Pain
Coffin et al., Annals of Internal
Medicine 2016
In a population with a rate of opioid-related emergency department visits of 7/100 person-years, prescribing
naloxone to 29 patients would avert 1 opioid-related visit in the subsequent year.
Participate!
• Prescribe to patients:
– Higher doses of opioids
– Using opioids illicitly or with a history of use
• Patients at risk of witnessing an overdose
– Insurance issues less clear
– Can also refer to community agencies
• Enroll your agency as a community program
– Particularly if serving high risk patients
• Opioid Maintenance & Mortality
In Baltimore, researchers found:
• Statistically significant inverse relationship between heroin OD
deaths and patients treated with buprenorphine (P = .002)
(Adjusting for heroin purity and # of methadone patients)
Schwartz et al AJPH 2013
Conclusions
• Provision of naloxone to patients and
community members is feasible and
efficacious
• Physicians can train, prescribe, refer to
programs depending and local resources
• An addition to, not a replacement for
evidence based treatment!
Acknowledgments
• New York State Department of Health
• New York City Department of Health and Mental
Hygiene
• Opioid Safety with Naloxone Network
• Injection Drug Users Health Alliance
Resources
NYSDOH:
http://www.health.ny.gov/overdose
– List of programs; registration information; calendar of
trainings and more
NYCDOH&MH
www.nyc.gov/html/doh/html/hcp/naloxone-odprev.shtml
– List of NYC pharmacies and more
HRC: http://harmreduction.org/issues/overdoseprevention/
– Updates, videos, soon lists of independent pharmacies
in NYS
QUESTIONS?