Kentucky Opioid Response Effort: A Strategic Action Plan

Allen J. Brenzel, M.D.,MBA

July 31, 2018

Outline

The Opioid Epidemic

• National

• Kentucky

Strategic Action Plan

• Prevention

• Treatment

• Recovery

• Infrastructure

Kentucky – We have a problem

• Crisis in number of individuals incarcerated in state correctional system (28,000)

• More than 9200 children in state custody• Exploding healthcare cost for OUD

related health care complications– OD E/R and admissions– Hepatitis/HIV Risk– Cellulitis/endocarditis/brain abscesses

Consequences of Opioid Crisis

2.1 million Americans with OUD

19,413 – Synthetic opioids excluding methadone

17,087 – Commonly prescribed opioids

15,469 – Heroin

116 people died every day from opioid-related overdoses

2016 National Survey on Drug Use and Health, Mortality in the United States;2016 NCHS Data Brief No. 293, December 2017

KY RESIDENT DRUG OVERDOSE DEATHS (all drugs)

197 241345

426

560 526638

728 708764 769

1007105810781019

1077

1273

1419

1565

0

200

400

600

800

1000

1200

1400

1600

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Year

Num

ber o

f Dea

ths

10.3% increaseNumber of Opioid-Related

Overdose Deaths in Kentucky

2017 Synthetic opioids increased to 763

AGE-ADJUSTED OVERDOSE DEATH RATE BY STATE, 2016

State Deaths PopulationCrude Rateper 100,000

Age-Adjusted Rate per 100,000

West Virginia 884 1,831,102 48.3 52.0

Ohio 4,329 11,614,373 37.3 39.1

New Hampshire 481 1,334,795 36.0 39.0

Pennsylvania 4,627 12,784,227 36.2 37.9

Kentucky 1,419 4,436,974 32.0 33.5

Maryland 2,044 6,016,447 34.0 33.2

Massachusetts 2,227 6,811,779 32.7 33.0

Rhode Island 326 1,056,426 30.9 30.8

KY DRUG OVERDOSE DEATHS BY AGE

Data source: Drug Overdose Deaths among Kentucky Residents, 2000-2016. Produced by the Kentucky Injury Prevention Research Center, July 2016.Data are provisional and subject to change.

2017 Ky Overdose Fatality Report

• Fentanyl was involved in 763 OD deaths

• Heroin was involved in 22 percent, down from 34 percent in 2016

• Alprazolam - 34% of cases

• Gabapentin - 29 %

• Methamphetamine - 28% (57% increase)

• Oxycodone - 13 % (6% decline)

• Hydrocodone - 13%(3% decline).

2017 OD Report

• Jefferson County had the most OD deaths with 426, up from 364 in 2016

• Other notable increases – Fayette County up 49– Campbell County up 26– Kenton County up 17

• Largest decreases– Madison County down 9– Bell County down 10– Knox County down 8

Neonatal Opioid Withdrawal

19 46 6998 123 133

179209

251

327379

522

632

756

1,060 1,043

1,115

725

982

890934

0

200

400

600

800

1,000

1,200

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Number

NAS Hospitalizations NAS Paid by Medicaid

COMPOSITE RISK INDEX

1) Fatal opioid overdoses

2) Opioid overdose ED visits

3) Opioid overdose

hospitalizations

4) MME ≥ 100

Opioid Overdose Index

10.5 - 36.5

36.6 - 55.3

55.4 - 72.5

72.6 - 111.0

Kentucky Opioid Overdose Index Score, 2017

Index score calculated by averaging county ranks in 1) fatal opioidoverdose rate; 2) opioid overdose emergency department visit rate;3) opioid overdose hospitalization rate; 4) MME >=100 rate.

Data sources: Kentucky Inpatient and Outpatient HospitalizationClaims Files, Frankfort, KY; Cabinet for Health and FamilyServices, Office of Health Policy; Kentucky Death CertificateDatabase, Kentucky Office of Vital Statistics, Cabinet for Healthand Family Services; Kentucky All Schedule Prescription ElectronicReporting, Kentucky Office of Inspector General, Cabinet for Health and Family Services. Data are provisional and subject to change.

Data sources: Kentucky Inpatient and Outpatient Hospitalization Claims Files, Frankfort, KY; Cabinet for Health and Family Services, Office of Health Policy; Kentucky Death Certificate Database, Kentucky Office of Vital Statistics, Cabinet for Health and Family Services; KASPER Quarterly Trend Report, Third Quarter 2015, Kentucky Department for Public Health. Data are provisional and subject to change.

E/D Overdose Visits All Drugs

Kentucky Injury Prevention and Research Center Dashboard

Kentucky’s Strategic Action Plan

• A framework for guiding the response

• Identifies priority targets, but not comprehensive

• Informs interventions span the continuum and include individuals, families, & communities

• Requires a multidisciplinary & transdisciplinary response

• Living action plan

Coordination Across Agencies

Governor’s Office

Health and Family Services

Justice and Public Safety

Education and Workforce

Development

Labor

Administrative Office of the

Courts

BHDIDDPHDMSDCBSOCSHNOIG (KASPER)OHDA

Office of Drug Control Policy (ODCP)

Building Blocks of the Action Plan Prevention

Prevent initiation of use

Prevent misuse

Prevent related harm

Expand universal prevention

Sources of Strength – increasing help seeking and promoting connections with peers and adults

Too Good for Drugs – social and emotional learning with drug use prevention

Lifeskills – Healthy alternatives to risky behaviors

Operation Prevention – Classroom tools aligned with national health and science standards

Prevention of Adverse Childhood Experiences (ACE’s)

Prevent Initiation of Use

Decrease access to opioids through public safety-based programs

38% - Got through prescription(s) or stole from healthcare provider

3.5% - Some other way

6% - Bought from drug dealer or other stranger

53% - Given by, bought from, or took from a friend or relative

Prevent Initiation of Use

Limit Exposure to Opioids

Quesinberry, D. KASPER Quarterly Threshold Analysis Report, Fourth Quarter 2017. Kentucky Injury Prevention and Research Center, 2018.

Prevent Initiation of Use

Limit Exposure to OpioidsOpioid Stewardship - appropriate utilization of opioids for pain management

Leadership committed, education, and culture

Organizational policies

Clinical knowledge and practice

Patient and caregiver education

Tracking and reporting quality metrics

Resources: National Quality Playbook, The Joint Commission R3 Report, CDC Guidelines for Prescribing Opioids for Chronic Pain

Prevent Initiation of Use

Limit Exposure to Opioids

Kentucky Chapter of the American Academy of Pediatrics Developed online webinar CME for pediatricians

Training pediatricians

Developed safe storage/disposal handouts

Trained pediatricians to distribute drug disposal kits

UK Healthcare

Opioid Stewardship programs for hospitals

Assist hospital in establishing a drug take-back program

Increase naloxone access and utilization

Prevent Initiation of Use

Decrease access to opioids through public safety-based programs● Prescription drop boxes● Prescription lock boxes● Drug take-back events

Prevent Initiation of Use

Safer prescribing and dispensing Kentucky All Schedule Prescription Electronic Reporting

2005 – 1st self-service, on-line system for tracking controlled substance prescriptions

3-day supply limit for acute pain

eKASPER Prescriber Report Cards

Drug conviction information (Class A misdemeanor or felony drug convictions)

Positive drug toxicology results for non-fatal overdoses

Warning flags on patient reports to indicate high levels of opioid prescribing

Prevent Misuse

Appropriate treatment for chronic pain

1. Patient assessment of Chronic Non-Cancer Pain Address psychiatric & behavioral health comorbidities

2. Patient education & treatment agreement

3. Pain management Non-opioid analgesics

Therapeutic exercise/ physical therapy

CBT

Complimentary and alternative medicine

4. Managing addiction risk

Prevent Misuse

Naloxone Distribution● DPH Mobile Van● HRSEP’s● Retail Pharmacy● Community Events● SUD Treatment Centers● Jails ● Emergency Departments

Prevent Related Harm

HRSEP Start-up/Stand-up Funding

• Funding provided to new and underfunded Harm Reduction Syringe Exchange Programs with the goal of supporting campaigns addressing– Stigma reduction

– Coalition building

– Education

– Naloxone distribution

– HIV testing and linkage to care

– Referral to treatment

– Health education/risk reduction counseling.

Prevent Related Harm

Prevention: What doesn’t work Scare tactics

Drug/paraphernalia displays

Stories by former drug abusers

General awareness/statistics

Information on drugs and their effects

Teaching signs and symptoms of addiction

Mock car crashes

Graphic images of people using drugs

Ohio Attorney General’s Drug Use Prevention Resource Guide, 2018

Treatment

Improve early identification of intervention need

Build pathways to treatment

Support utilization of a full treatment continuum

Integrate and coordinate service delivery

Hypothetical SUD Cascade of Care100%

0%

50%

75%

25%

Population 12+ w/ SUD

Diagnosed by a

healthcare provider

Received any type of treatment

Received tailored

evidence-based

treatment

Accessed chronic relapse

prevention care

Long-term recovery

?

?

??

?

12%

Socías et al., 2016

Universal screening through SBIRT Immediate rule out of non-problem users

Identification of levels of risk

Provides a context for discussion of substance use

Identification of patients who would benefit from brief advise

Identification of patients who would benefit from a referral for further assessment

Indication of the appropriate intervention type

Identification of Intervention Need

Clinical assessment and service planning

Identification of Intervention Need

Increase access to and awareness of treatment resources for clients and providers

findhelpnowky.org

Pathways to treatment

Increase treatment initiation and engagement through behavioral health and other partners

Emergency Departments

Primary Care

Local Health Department

Criminal Justice System

Rapid Response Teams

Many others…

Pathways to treatment

ED Bridge Clinic Model

• Inform of treatment availability

• On-site peer engagement

• Hepatitis, HIV testing

Identify and Connect

• Buprenorphine to treat withdrawal OR

• Motivational interviewing and referral to MAT

Treat in ED• Navigator to

connect to treatment and/or harm reduction

• Naloxone at discharge

Refer and Reduce Harm

• Peer support follow-up

• Recovery Supports

Follow-Up

Pathways to treatment

Treatment Stipend ProgramObjective: Increase rapid access to evidence-based OUD treatment for individuals who would otherwise not receive treatment

Eligible programs:

• Licensed AODE/BHSO residential programs

• CMHCs with residential and/or IOP

• Provide and do not limit access to MAT

Eligible clients: • Have an OUD

• Income not exceeding 150% FPL

• Ky resident

• Lack a payer source

Pathways to treatment

Treatment: What doesn’t work

• Detoxification alone

• Referral to treatment without follow-up and support

• Education alone

• Mandatory medication tapering

• Failing to treat comorbidities

Pathways to treatment

Integrate and coordinate service delivery

Integrate healthcare with MAT and SUD services

Implement coordinated systems of care

Increase utilization of case management to

coordinate care

Integrate and coordinate delivery

Increase access and availability of a full continuum of services

Access – the equitable distribution of services

Availability – a sufficient supply of services

Outpatient Services

Intensive Outpatient/Partial Hospitalization Services

Residential/Inpatient Services

Medically Managed Intensive Inpatient Services

Full continuum of services

Integration of peer support

Delivered by individuals who have common life experiences with the people they are serving

• Assertive outreach

• Community education

• Advocacy

• Empowerment & leadership development

• Recovery capital assessment

• Recovery planning and wellness

• Assertive linkages to community resources

• Recovery focused skills training

• Companionship and modeling

• On-going recovery management

• Health system navigation• Crisis support

Integrate and coordinate delivery

Pregnant and Parenting Woman• Identification of Woman Prenatally• Coordinated Care Model

– High quality prenatal care– Medication Assisted Therapy (Buprenorphine and

Methadone)– SUD Services

• Residential• Intensive Outpatient• Individual• Peer Support• SUD Case Management

– Nurse Care Coordinator Function– Hospital, Pediatric and Neonatalology involvement

• Post-delivery, mother and infant follow-up

RECOVERY

Expand transitional care services

Expand community support services to support long-term recovery

Expand transitional care services

Expand recovery support including case management and peer support

Recovery community centers – a central hub for obtaining recovery services

Recovery Coaching

Support group meetings

Education

Parenting training

Transitional Care

Grow, diversify, and increase access to MAT-friendly recovery communities

Young People in Recovery

Double Trouble in Recovery

Self-Management and Recovery Training

Transitional Care

Expand community support services to support long-term recovery

Access to quality recovery housing

Recovery-oriented workplaces to support employee

and employer

Recovery capital through education and job training

Recovery support services for family and friends

SMART Recovery Friends & Family

Community Support Services

EMPLOYMENT SUPPORT

• Employment supports through the Department of Corrections for individuals re-entering the community

• Employer toolkit to guide employers’ understanding of OUD in the workplace and to provide best practice recommendations for prevention, treatment, and recovery support

Decrease stigma and barriers

INFRASTRUCTURE

Decrease stigma and other barriers to treatment

Obtain and produce actionable data

Foster quality SUD services

Support expansion of the provider network

Deliver broad-based education and public service messaging around addiction prevention, treatment, and recovery to reduce stigma

• Don’t Let Them Die! http://dontletthemdie.com/

• KET’s Inside Opioid Addictionhttps://www.ket.org/health/opioids

Decrease stigma and barriers

Decrease structural barriers to accessing services• Transportation

• Financial

• Employment

• Childcare

• Record expungement

Decrease stigma and barriers

Integrate datasets and improve real-time data collectionSyndromic surveillance - using health-related data that signal a sufficient probability of a case or an outbreak to warrant further public health response

Actionable Data

Expand data-driven decision-making

Actionable Data

Opioid Overdose Index

10.5 - 36.5

36.6 - 55.3

55.4 - 72.5

72.6 - 111.0

Kentucky Opioid Overdose Index Score, 2017

Index score calculated by averaging county ranks in 1) fatal opioidoverdose rate; 2) opioid overdose emergency department visit rate;3) opioid overdose hospitalization rate; 4) MME >=100 rate.

Data sources: Kentucky Inpatient and Outpatient HospitalizationClaims Files, Frankfort, KY; Cabinet for Health and FamilyServices, Office of Health Policy; Kentucky Death CertificateDatabase, Kentucky Office of Vital Statistics, Cabinet for Healthand Family Services; Kentucky All Schedule Prescription ElectronicReporting, Kentucky Office of Inspector General, Cabinet for Health and Family Services. Data are provisional and subject to change.

Feedback of data to local communitiesPublic-facing dashboards

Actionable Data

Promote quality standards

• Conduct a comprehensive review of all current state licensure and quality standards that apply to substance use disorder treatment and recovery services and programs that operate within the Commonwealth of Kentucky

• Develop enhanced licensure and quality standards for substance use disorder treatment and recovery

• Establish a data monitoring system to support quality services and improved outcomes

Quality SUD Services

Decease service delivery barriers through red tape reduction• Pre-authorizations

– Remove or reduce burden

• Payment barriers

– Treatment stipend Program

• Reimbursement rates

– Incentivize use of evidence-based practices

Expand Provider Network

Building Blocks of the Action Plan

Contact Info

allen.brenzel@ky.gov

katie.marks@ky.gov