AnUpdateontheEvolvingMDHHSStrategyforCombattingtheOpioid

MortalityCrisis

MICHIGANDEPARTMENTOFHEALTH&HUMANSERVICES

P u t t i n g p e o p l e f i r s t , w i t h t h e g o a l o f h e l p i n g a l l M i c h i g a n d e r s l e a d h e a l t h i e r a n d m o r e p r o d u c t i v e l i v e s , n o m a t t e r t h e i r s t a g e i n l i f e . 1

DavidR.Neff,DOChiefMedicalDirectorOfficeofMedicalAffairs

MedicalServicesAdministrationMichiganDepartmentofHealth&HumanServices

AssistantClinicalProfessorDepartmentofFamily&CommunityMedicine

MichiganStateUniversityCollegeofOsteopathicMedicine

Objectives1. DescribethechanginglandscapeoftheOpioidMortalityCrisisin

2017

2. ProvideanOverviewoftheEvolvingMDHHSStrategytoCombattheCrisis

3. WhatYou,theProvider,CanDoToMinimizeRiskforOpioidUseDisorder,OverdoseandDeath

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TheRapidlyChangingLandscapeoftheOpioidMortalityCrisisin

2017

Six Days of Drug Overdose: Cincinnati

ü In a six day period (August 19-24, 2016) Cincinnati area experienced 174 opioid overdose reactions.

ü The culprit responsible was heroin cut with a fentanyl analogue: Carfentanyl.

ü Carfentanyl is 10,000 times as potent as morphine.ü Carfentanyl is used to tranquilize elephants.

https://www.washingtonpost.com/news/morning-mix/wp/2016/08/29/this-is-unprecedented-174-heroin-overdoses-in-6-days-in-cincinnati/?utm_term=.c8e4154fc9e6

Carfentanyl Deaths in Michigan

ü September15,2016-Firstdocumentedcarfentanyloverdose seen in Kent County

ü October 6, 201619 confirmed carfentanyl overdose deaths in Wayne County since July

http://www.michigan.gov/mdhhs/0,5885,7-339--393468--,00.htmlhttp://www.michigan.gov/mdhhs/0,5885,7-339--395078--,00.html

U-47700 Death in Michigan

ü October5,2016- FirstdocumentedU47700 (aka, pink) overdose seen in White Lake, MI

ü ThethenlegaldrugwaspurchasedovertheinternetandshippedfromChina

ü ItwasdesignatedasaScheduleIrestricteddruginNovember,2016

http://www.cnn.com/2016/11/01/health/u-47700-pink-drug/index.html

Grey Death in GA, FL, OH and WV

ü May4,2017- GrayDeathisacombinationofseveralpowerfulsubstancessuchasHeroin,Fentanyl, Carfentanil andasyntheticopioidcalledU-47700

ü Thedrughastheappearanceofaconcreterock.Itischunkyandsolid,createdfromcompressedandcookedpowder

ü Atleast50peoplehavereportedlyoverdosed,somedyingaftertheirfirstdoseofthedrug

http://www.cbsnews.com/news/gray-death-opioid-dangerous-drug-combination/

https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?_r=0AdaptedfromCDC•NationalCenterforHealthStatistics•NationalVitalStatisticsSystemasof8/16/17

TotalUSDrugDeaths2000-2016Onaverage142peopledieeachday

DrugOverdoseDeathsintheUS2000-2016Fentanyl,FentanylAnaloguesandHeroinareOutpacingPrecipitationOpioidDeaths

https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?_r=0AdaptedfromCDC•NationalCenterforHealthStatistics•NationalVitalStatisticsSystemasof8/16/17

AmongOpioids,RatesofDrugOverdoseDeathsAmongAdolescentsAged15–19in2015WereHighestforHeroin

NCHSDataBrief■ No.282■ August2017

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Total Drug Poisoning Deaths in MI, 1999-2016*

Source: Michigan Death Certificates, Division for Vital Records and Health Statistics/MDHHS*2016 is provisional, total is expected to change.

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DataSummary

*Provisionaldata

*ProvisionalData

**2015Data

Indicator 2011 2016Alldrugdeaths 1,359 2,335*Allopioiddeaths 622 1,689*Opioidprescriptions 10,441,714 11,028,495Neonatal abstinencesyndrome cases

630 927**

People insubstanceusedisordertreatmentforopioidsorheroin

22,234 32,473

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EstimatedPopulationUsingPrescriptionOpioidsinMichiganin2016

Prescriptions Medicaid(Actual)

CommercialandNo-Insurance(Estimated)

Total(Estimated)

30 Days 402,154 1,206,462 1,608,616

90Days 115,841 347,523 463,364

365Days 21,847 65,541 87,388

1/3 of the Population Has Some Form of Pain1/6 of the Population Took an Opioid

WhenthePrescriptionIstheProblem

*

*In2010,theratewas4xhigherthan1999

MMEs prescribed per capita (2015) Change in MMEs prescribed per capita (2010–2015)

ChangesinOpioidPrescribingintheMichigan,2010-15(ExcerptedFromaNationalReportfromtheCDC)

DataFromDrugUsersRespondingtotheDEANDTASurvey– 2/3ofPrescriptionOpioidsWereObtainedForFree,BoughtorStolen

2017NationalDrugThreatAssessment

• MuchofThisUseStartedforRecreationalandNotMedicinalPurposes• OncePrescribed,DistributionisLargelyOutofPrescribers’Hands

DataFromDrugUsersRespondingtotheDEANDTASurvey– 2/3ofPrescriptionOpioidsWereObtainedForFree,BoughtorStolen

2017NationalDrugThreatAssessment

• MuchofThisUseStartedforRecreationalandNotMedicinalPurposes• OncePrescribed,DistributionisLargelyOutofPrescribers’Hands

WhenHeroinistheProblemTheNationalHeroinThreatistheGreatestintheNortheastCorridorandtheMidwest

In2015-16– HeroinBecametheGreatestNationalThreatAstheControlledPrescriptionDrug(CPD)ThreatDiminished

Heroin

CPD’s

WhenFentanylAnaloguesAretheProblem— OverdoseDeathsinOhio,January–February2017

TheCauseForManyOverdoseDeathsCannotBeDeterminedWhenSyntheticOpioidsAreNotMeasured

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AnOverviewoftheEvolvingMDHHSStrategytoCombatthe

CrisisDavidR.Neff,DO

ChiefMedicalDirectorOfficeofMedicalAffairs

MedicalServicesAdministrationMDHHS

DebraA.Pinals,M.D.ChiefPsychiatrist

MedicalDirectorof BehavioralHealthandForensicPrograms

BehavioralHealthandDevelopmentalDisabilitiesAdministration(BHDDA)

MDHHS

EdenV.Wells,MD,MPH,FACPMChiefMedicalExecutive

MichiganDepartmentofHealthandHumanServices

MedicalDirector,PopulationHealth

Reduce Supply and Demand

Early Intervention

Increase treatment services

Increase emergency services

1°

2°

3°

Prevention

Early Intervention

Treatment

Improve IT Analytics & Surveillance

Promote awareness

Identify Risk of Addiction & Overdose

Use Screening Tools (ie, SBIRT, DAST-10)

Rescue w/Naloxone

Stabilize w/MAT

Recover w/ CBT & DBT

Community ProgramsSchools

Slow Taper

Reduce Opioid Pill Counts

Informed Consent &Treatment Contracts

MAPS Narcs Care Narcs Rx MIHIN CC360

Parenting Skills

Mentoring Skills

Reduce Illicit Rx & Heroin Trafficking

Take-back Programs

Coping Skills

Identify Underlying Conditions & Comorbidities

Treat Pain w/Fewer Opioids

Multimedia Campaigns

MDHHSPublicHealthStrategicFrameworktotheOpioidCrisis

TheEvolvingStrategyisDesignedtoEmbraceAllStakeholderGroupstoHelpIndividualsandtheEntirePopulation

IndividualHealth

PopulationHealth

MDHHS LAARLARADepartment

ofEducation

PayersHealthPlans&Hospitals

LawEnforcement

&Courts

Communities(PTA’s,HeadStart,FaithBased

Programs)

APersonCenteredCommunity-basedActionPlanRequiresAllStakeholders

Payers

PersonSufferingAddiction

MDHHS

FundingSources•Medicaid

•HealthyMichigan

•SubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)BlockGrant

•GeneralFund•OthergrantsoStateTargetedResponse(STR)oCentersforDiseaseControl(CDC)o1115Waiver(Pending)

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ServicesFundedbyMedicaidServicesfundedinclude:

•MedicationAssistedTreatment

•Detoxification•OutpatientServices•CaseManagement

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Medicaid&HealthyMichigan•Medicaidpaidover$41millioninsubstanceusedisorderservicesprovidingservicesto31,101beneficiariesinfiscalyear2016

•HealthyMichiganpaidover$53millioninsubstanceusedisorderservicesprovidingservicesto28,850beneficiariesinfiscalyear2016

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michigan.gov/stopoverdoses

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Latest Improvement Starting 11/1 - Sample Risk Score for the Electronic Health Record

PreservingandExpandingOurProviderWorkforceByCreatinga

LearningHealthSystemApproachtoImproveProviderExpertise

CreatingaLearningHealthSystemApproachtoImproveProviderExpertise

• Providersarecoretohelpingaddressthecrisis• thereisvariabilityinexpertiseandnumberswhoareableandwillingtoparticipate

• Theproviderworkforceisverywillingtoimprovepracticepatternsbasedonevidence-basedrecommendations,butneedsassistance

• Thereisahighneedtorapidlyreorientproviderstoresponsiblymanageopioids• whenandhowtostartandstopopioids• howtoidentifyriskforaddictivebehaviors• howtoidentifyriskforoverdose• howtobestassistpatientswhentheseriskbehaviorsoccur

• Thecoreprincipleistoembracea“learninghealthsystem”approachutilizingrealworlddatasourcestoapply“teachablemoments”

• ThisconceptisadaptedfromthetransformationalworkandresearchofPeterSengeandhiscolleagues.[1]

• alearningorganization facilitatestheongoinglearningofitsmembersandcontinuouslytransformsitself

[1]Senge,P.M.(1990).Theartandpracticeofthelearningorganization.Thenewparadigminbusiness:Emergingstrategiesforleadershipandorganizationalchange,126-138.

TakingaCollaborativeApproachinEmbracingALearningHealthSystem• ProfessionalSocieties

• MOA• MSMS• MISAM• MPS• MAFP• MDA• MAPA• MCNP• MHA

• Payers• MAHP• BlueCrossBlueShieldofMI• OtherCommercial

• ProfessionalDegreePrograms

• MD(Underway)• DO(Underway)• PA(Planned)• NP(Planned)• DDS(Planned)• DPM(Planned)• DVM(Planned)• PharmD(Planned)

PROVIDERCOLLABORATION- JOINT10-POINTPLANTOCOMBATTHEOPOIDMORTALITYCRISIS

1. DevelopanddisseminateaclearlydefinedandactionableoverarchingstatespecificguidelinethroughtheMichiganQualityImprovementConsortium(MQIC)thatincorporatesthe2016CDCPainGuidelines,theASAMAddictionGuidelines,otherevidencebasedbestpracticesand utilizationofkeydatasourcesthathelpdriveclinicaldecisionmakingsuchasMAPSandthesoontobereleasedNarxCare riskscoringtoolsthatcanbeembeddedintheindividualelectronicmedicalrecord.

2. DevelopandteachtoaUniformCoreEvidence-basedOpioidCurriculumthroughprofessionalschools,professionalsocieties,hospitalsandhealthplansa. Whenandhowtosparinglyinitiateopioidsincludinglimitingquantitiesforacutepainmanagementb. Whenandhowtodeterminewhetherornotanopioidshouldbecontinuedc. Whenandhowtotaperandtaperopioidsasrapidlyaspossibled. Howtomonitorforopioidtolerance,dependenceandaddictionandeithertreatorreferearlyifindicatede. Howtoappropriatelydocumentinthemedicalrecordtherationaleandtreatmentcourseofusingopioids

3. DevelopReferralCentersofExcellence&TelemedicineConsultationCallCenterstoassistprovidersmanagecomplexpainandaddictioncases

4. LeverageMAPSandNarxCare RiskIndexScorestodrivepointofcaredecisions

5. DevelopaPeerReviewProcesstoassistproviderswhoareoutliersinprescribingbehavior

6. Developopioid-relatedqualitymetricsthatrewardprovidersfordeliveringhighqualitystandardofcare

7. SupportManagedCareandPharmacySpecificProgramstocontrolhighdosesandquantitiesofprescriptionopioidsandrequirejustificationiftheyarerequireda. PharmacyPriorAuthorizationprocessb. DrugUtilizationReviewc. MedicationTherapyManagement(MTM)bypharmacistsatthePointofSale(POS)d. BeneficiaryMonitoringProgram(BMP)lock-innprograms

8. Supportcommunitybasededucationprogramstopreventinappropriatedruguseinthefirstplaceandeliminateculturalmoresthatpromoteatypicaldrugbehavior

9. Workcloselywithlawenforcementtoeliminateillicitdrugsfromourcommunities,fullynotingthatillicitlytraffickedheroin andfentanylanaloguesarenowoutpacingprescriptionopioidrelateddeathsin2015-2017

10. Supporteffortstoimprovesurveillanceanddetectionofopioidrelateddeathsincludingimprovedtoxicologyscreeningforpreviouslyundetectablefentanylanalogues

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WhatYou,theProvider,CanDoToMinimizeRiskforOpioidUseDisorder,OverdoseandDeath

OtherNon-opioidPainManagementStrategiesIncludingCross-functionalTeamApproaches1. Osteopathicand

ChiropracticManualMedicine

2. EpiduralandFacetBlocks(forspinalpain)

3. RadiofrequencyAblation4. ComplexRegionalPain

SyndromeTechniques5. MeditationandYoga

Techniques

WhatElseCanYouDotoPreventAddiction,OverdoseandDeath– StartingOnMonday1. StayabreastwiththeconstantlyevolvingfactsthatuncovertherootcausestheOpioidEpidemic

2. RememberOpioidToleranceStartsSomewhereBetween3-7days

3. Don’tAbandonPatientswithLife-alteringPainorForcePatientsTakingLongTermOpioidstotheStreet

4. TakeaTeam-basedapproachandDon’tGoitAlone– Surgery,RehabilitationMedicince,PainManagement,AddictionManagement,BehavioralHealth

5. StartConversationsattheFirstDayofPrescribingOpioidsandContinueThemwithPatientsToDiscussThatOpioidsNeedtoBeStoppedAsSoonAsPossible

6. MonitorandScreenforTolerance,Dependence,AddictionandRiskforOverdoseandDeath

7. LearnHowtoAppropriatelyTaperExistingOpioidsandDetermineIfAnUnderlyingOpioidUseDisorder(OUD)Exists

8. UtilizePatientContractsThatIncludeMeaningfulInformedConsent

9. UseMAPSFrequentlyToDetectPatternsofMisuseorAbuseandEnsureBothCoordination&ContinuityofCarewithOtherProviders

10. UseUrineDrugScreenstoCheckforComplianceandPotentialIllicitDrugUse

11. TreatorReferEarly

12. Writefornaloxonetopatientswhoareathighriskforoverdose

13. ObtainaxDEA waivertohelpstabilizepatientswithOpioidUseDisorder(RegardlessoftheReason)

14. GetInvolvedwithYourCommunitytoStopCulturalExpectationsThatEncourageIllicitDrugUse

15. WorkThroughYourProfessionalSocietiesandPersonallyTalktoYourLegislatorsandRegulatorstoShareYourExperiencesandWhatTheyCanDotoHelpYou

Summary• Therootcausesfortheopioidepidemicarecomplexandmultifactorial

• Itisimperativetoshrinksupplyanddemandforbothprescriptionopioidsandheroin/fentanylanalogues

• Awellorganizedstate-wideplanisnecessarytoavoidabandoningpatientswith“true”painandalsonotsendpeopletothestreetforheroinandsyntheticopioids

• Focusingonlyonprescriptionopioidswithoutsimultaneouslyaddressing“heroinandfentanyltrafficking”willdramaticallyshrinkprobabilityofsuccess

• Mostofallitwill“takeavillage”– “everyvillage”hereinMichigan

Email:neffd2@michigan.gov

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