The Opioid Crisis: An AHEC’s Series of Funded Projects

David A. Gross, MPA2019 KACHW Conference Lexington, KY

Why I’m here today

‘What the heck’s an AHEC?’ Created by Congress in the

1970s to enhance access to quality health care

Four strategies: Health careers promotion Facilitate clinical rotations Continuing education Community health

Total population: 321,785Source: U.S. Census Bureau, 2015

About Northeastern Ky. Our counties: 14 of the 17 are categorized as rural 16 of the 17 are Appalachian

11 of those are designated as ‘distressed’

Median household income: $36,410 High rates of cancer and other chronic diseases,

but several counties are HPSAsSources: USDA Economic Research Service, 2013; Appalachian Regional Commission, 2016; RWJF/PHI County Health Rankings, 2015

Source: Centers for Disease Control and Prevention

Appalachia at high risk …https://overdosemappingtool.norc.org/

… particularly NE KYCounty OD Deaths Rate1. Boyd 27 60.492. Madison 46 57.623. Kenton 91 56.434. Clark 19 51.165. Campbell 47 49.436. Greenup 15 44.957. Montgomery 13 44.038. Carter 10 40.27

Rate is per 100,000 residents; data from 2018 Kentucky Overdose Fatality Report

Continuing Education Kentucky Medical Association (KMA) Mason County Health Department

Mason County Health CoalitionMeadowview Regional Medical Center Program goal:

To educate physicians and other prescribers about unintended consequences, for both the prescriber and the patient, from prescribing patterns of certain medications such as opioids.

To review safer prescribing practices and policies to prevent starting an addiction, perpetuating an addiction, or interfering with recovery in patients.

To review the Surgeon General’s program #turnthetiderx, and the utilization of eKASPER.

‘The Power of Prescribing: Addiction Consequences

of Opioid Rx’ Held Jan. 26, 2017, in Maysville, Ky. 72 total attendees Physicians, NPs, PAs, pharmacists, dentists, etc.

Strong provider feedback following event

Opioid MAT grant (2017-’19) HRSA Primary Care Training and Enhancement Medication-assisted Treatment Supplement

Focus is opioid use disorder diagnosis, prevention, and treatment, emphasizing MAT: Combines medication and counseling to treat SUDs

Integration into the core curriculum of the medical education program;

Faculty training (e.g., train-the-trainer model) Enhancement of primary care training sites to provide these

services

PCTE: Year 1 Project OverviewActivity Date Title Location Contact

HoursTotal

Attendees

8/4/2017 A Family Physician's Role in Addressing the Opioid Epidemic Lexington, KY 4.75 838/16/2017 Interdisciplinary Grand Rounds: Drugs of Abuse & Addiction Morehead, KY 1 23

9/23/2017Fall Pharmacy Forum: 2017 Legislative Update & Current Issues with Controlled Substances Olive Hill, KY 5 13

10/3/2017 SOAR Provider Education Substance Use Disorder Morehead, KY 5 7110/10/2017 Neonatal Outreach Education: Women and Addiction Winchester, KY 1 610/13/2017 KRBHS: The Local Opioid Epidemic: A Law Enforcement Perspective Morehead, KY 1 5312/5/2017 The Opioid Crisis: Prescribers' Role and Treatment Options Ashland, KY 2.5 281/24/2018 Due Diligence in the Prescribing of Opioids and Other Controlled Substance Morehead, KY 2 312/27/2018 Power of Prescribing: Addiction Consequences of Opioid Rx Winchester, KY 3 894/25/2018 Substance Use, HIV, and Hepatitis C: Appalachia at Risk (Young Travel CE) Morehead, KY 1 196/1/2018 Physician Assistant Student Rural Health Symposium Morehead, KY 4.75 60

6/13/2018 Substance Use, HIV, and Hepatitis C: Appalachia at Risk (Young Travel CE) West Liberty, KY 1 157/18/2018 The Disease of Addiction West Liberty, KY 1 98/7/2018 The Next Era in Hepatitis C Treatment Bring Cure to Primary Care Morehead, KY 1.5 32

8/15/2018Interdisciplinary Grand Rounds: ABC's of Viral Hepatitis: Public Health Update for KY Healthcare Workers Morehead, KY 1 19

9/5/2018 Recovery and Solutions: The Next Chapter in Northeast Kentucky’s Opioid Epidemic Morehead, KY 2.75 197

4 physicians and 1 nurse practitioner MAT-waivered

PCTE: Year 2 Project OverviewActivity Date Title Location Contact

HoursTotal

Attendees

10/12/2018 KRBHS: Let’s Talk About the Kids: A Look at How Addiction Affects Families Morehead, KY 1 5811/27/2018 Treating the Whole Patient: Addiction Medicine is Primary Care Medicine (Zook) Morehead, KY 1 192/11/2019 Medication-Assisted Treatment Waiver Course (SCR FM Residents) Morehead, KY 4 133/18/2019 MAT 101 Flemingsburg, KY 1 133/18/2019 MAT 101 Ashland, KY 1 43/20/2019 Basic MAT 101 and Panel Discussion Morehead, KY 2 143/21/2019 MAT 101 Maysville, KY 1 163/26/2019 Basic MAT 101 and Panel Discussion Mt. Sterling 2 134/26/2019 Medication-Assisted Treatment Waiver Course Morehead, KY 4 TBD

Total –# of activities: 25# of attendees: 886

Assisted 10+ providers in becoming MAT-waivered

Spin-off projects Completed:

HRSA Rural Health Network Development Planning grant: “NE KY Opioid Crisis Response Network” (2017-’18) In partnership with St. Claire HealthCare, Pathways Inc.,

Sterling Health Solutions, and Gateway District Health Department

Cardinal Health Foundation: “Prescription Education for Appalachian Kentucky Students (PEAKS)” (2018-’19)

MAT-focused Project ECHO in collaboration with the Kentucky Rural Healthcare Information Organization (2018-’19)

HRSA AHEC Supplement (2018-’19)

Spin-off projects (continued) Under way:

HRSA Rural Communities Opioid Response Program-Planning grant: “NE KY Opioid Crisis Response Consortium” (2019-’20) In partnership with St. Claire HealthCare, Comprehend

Inc., Kentucky Rural Healthcare Information Organization, Clark County Health Department, Achieving Recovery Together, and Tri-State Primary Care

Peer recovery specialists = community health workers? Lessons learned from Dopesick author:

Be willing to get your a-- kicked (and get out of your silos) Innovate – even if you have to ‘go all holler’

Sustainable funding possibilities HRSA Rural Communities Opioid Response Program-

Implementation grant RCORP-MAT Expansion grant Bureau of Justice Assistance “Rural Responses to the Opioid

Epidemic” grant Foundation for Opioid Response Efforts “Improving Access to

OUD Treatment and Recovery Services” grant HRSA Rural Health Network Development grant HRSA Rural Health Care Services Outreach Program grant

References Appalachian Regional Commission. ARC-designated distressed counties, fiscal year 2016.

Available at www.arc.gov/distressedcounties. Blodgett M. Rural grant program combats opioid overdose epidemic. Rural Horizons. Spring 2017.

Available at https://www.ruralhealthweb.org/news/content-hub/rural-horizons-magazine. Davis JH. Trump declares opioid crisis a ‘health emergency’ but requests no funds. The New York

Times. October 26, 2017. Available at https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html.

Healy M. In rural America, opioid prescriptions continue to flow, new CDC report shows. Los Angeles Times. July 6, 2017. Available at http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-prescriptions-20170706-story.html.

NORC at the University of Chicago. Appalachian Overdose Mapping Tool. 2018. Available at https://overdosemappingtool.norc.org/.

Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. County Health Rankings. 2015. Available at www.countyhealthrankings.org.

Temple KM. What’s MAT got to do with it? Medication-assisted treatment for opioid use disorder in rural America. The Rural Monitor. March 21, 2018. Available at https://www.ruralhealthinfo. org/rural-monitor/medication-assisted-treatment/.

References U.S. Census Bureau. State & County Quick Facts. 2015. Available at http://quickfacts.census.gov. U.S. Centers for Disease Control and Prevention. Illicit drug use, illicit drug use disorders, and

drug overdose deaths in metropolitan and nonmetropolitan areas – United States. Morbidity and Mortality Weekly Report. 2017, Vol. 66, No. 19.

U.S. Centers for Disease Control and Prevention. Opioid painkiller prescribing infographic. 2014. Available at https://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html.

U.S. Department of Agriculture, Economic Research Service. Rural-urban continuum codes. 2013. Available at www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx.

U.S. Department of Health & Human Services, Health Resources and Services Administration. HPSA Find. 2016. Available at http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx.

David A. Gross, MPANortheast Kentucky AHEC

316 W. Second Street, Suite 203Morehead, KY 40351

david.gross@st-claire.org(606) 783-6468

D I S C O V E R Y O U R D E S T I N Y

Residential Centers

Transitional Learning Centers

Outpatient Centers

30+ Programs in 12 Counties

Upcoming Facilities

L E A D I N G T H E W A Y I N K E N T U C K Y

• Admitted first Medicaid residential patient January 2015

• Admitted over 6,000 patients for residential treatment

• We accept most private insurance plans

WE ACCEPT ALL KENTUCKY MEDICAID PLANS

T R E A T I N G & T R A I N I N G P E O P L E I N R E C O V E R Y

First Peer Support Specialist Academy Class, May 2017

B A C K G R O U N DA D D I C T I O N R E C O V E R Y C A R E

• Tim Robinson, CEO & Founder

• Former prosecuting attorney and functioning alcoholic.

• December 11, 2006 sobriety date.

• August 2008 resigns as prosecutor and gives law practice to partner.

• December 2010 Karen’s Place, recovery center for women, opens in Louisa, Kentucky.

T R E A T M E N T O N D E M A N D

2 4 / 7 I N T A K E D E P A R T M E N T

Average wait time for a bed for someone who has insurance and passes phone screen:

72 hours

H O L I S T I C A P P R O A C H T O C A R E

Vocational(purpose)

Spiritual(soul)

Medical(body)

Clinical(mind)

D R . M I C H A E L F L E T C H E RC H I E F M E D I C A L O F F I C E R

• Addictionologist, American Board of Addiction Medicine (ABAM)

• President of Kentucky Chapter of American Society of Addiction Medicine (ASAM)

• Kentucky Board of Medical Licensure (KBML)

• Supervises Primary Care Physician, NP’s and RN’s

N A T I O N A L L Y A C C R E D I T E D

Accredited by Commission on Accreditation of Rehabilitation Facilities (CARF)

Drug and Alcohol Treatment Centers

CARF Standards Compliant

Pastoral Counselors Chaplains

S P I R I T U A L I T Y P R O G R A M

Celebrate Recovery

Women’s center in Lawrence

County, KY

Men’s center in Fleming County, KY

Men’s center in Pulaski

County, KY

K A R E N ’ S P L A C E M A T E R N I T Y C E N T E RT H R O U G H D E L I V E R Y P L U S 3 M O N T H S

K E E P I N G M O M A N D B A B Y T O G E T H E R

Blue Angels

Average NICU stay for a drug addicted baby

(without ARC treatment)

Average hospital stay for babies born at ARC’s

maternity center

5

1 0

1 5

2 0

< 5 days

20+ days

Recovery Skills

Clinical & Medical

Phase 1(Avg 30 days)

Phase 2(Avg 45 days)

Phase 3(60 days)

Phase 4(6-9 months)

Life Skills

Job Skills

F R O M C R I S I S T O C A R E E RA M U L T I P H A S E A P P R O A C H

>80% success rate for people who complete all four phases

OUTPATIENT CENTERS• Louisa

• Lexington

• Mt. Sterling

• Prestonsburg

• Crestview Hills

• Morehead

• Ashland

• Inez

M A T D O N E R I G H TA M O D E L P R O G R A M

• 8 patient visits per month initially. Patient-centered approach.

• Employed physicians taper program

• Counseling

• Case Management/WRAP

• Peer Support

• Drug Screens

• Medication Counts

• Chaplains

• Vocational Training

S U B O X O N E D I V E R S I O N R A T E S

Nationally:54%

ARC:3%

C O S T B E N E F I T B Y P U B L I C I N V E S T M E N T

Aos, Steve. “The Comparative Costs and Benefits of Programs to Reduce Crime.” (May, 2001). Washington State Institute for Public Policy; Robert Wood Johnson Foundation Study on Benefit and Costs of Substance Abuse Treatment, August 2006; www.drugabuse.gov study on MAT programs.

Treatment in Prison Drug Court MAT Job

TrainingResidential Treatment

$1.91$2.83

$4.00$5.28

$7.00

$7.00 ROI for $1: Residential

$4.00 ROI for $1: Outpatient$5.28 ROI for $1: Job Training

T R E A T M E N T & T R A I N I N G

What if we combined them?

A R C ’ S T R E A T M E N T C E N T E RS T A F F T R A I N I N G P R O G R A M

• Treatment Center Staff Training

• Staff Internship Program at ARC

• Guaranteed job (1 year clean).

• Career Paths:

‣ Residential Center Staff

‣ Residential Center Management

‣ Office Assistants

‣ Drug Screen Collectors

‣ Peer Support Specialists

‣ Corporate Office

• In recovery since December 2010

• From: IV Needle User

• Now:

‣ Homeowner

‣ College Graduate

‣ Center Director

‣ Business Owner

V A N E S S A K E E T O NK A R E N ’ S P L A C E G R A D U A T E

M A T T B R O W NB E L L E G R O V E S P R I N G S G R A D U A T E

• In recovery since May 2014

• From: HS Valedictorian/Licensed Physical Therapist with Pain Pill Addiction

• Now:

‣ Chief of Staff to CEO

‣ Louisa City Council

‣ Community Activist

‣ Pastor

• In recovery since January 2014

• Former IV Opiates User

• Military Veteran (Iraq and Afghanistan)

• From: PTSD; addicted veteran

• Now:

‣ Residential Services Manager (Men)

B R A N D O N L E S L I EB E L L E G R O V E S P R I N G S G R A D U A T E

P E E R S U P P O R T S P E C I A L I S T

One year clean and sober

40 hour training course & exam

Medicaid billable service

Behavioral Health Practitioner

A N E W P R O F E S S I O N I N K E N T U C K Y

P E E R S U P P O R T S P E C I A L I S T A C A D E M Y

• Sullivan University• EKCEP• College Credit• State Certifications• “Super PSS”

1 6 G R A D U A T E S• 14 paying taxes

• 14 now employed

• 14 helping others recover

• 14 transitioning off of Medicaid

> 8 0 % O F P S S A C A D E M Y G R A D U A T E S A R E I N R E C O V E R Y A N D E M P L O Y E D .

P E E R S U P P O R T S P E C I A L I S T S I N N E E D L E E X C H A N G E S , D E T O X E S ,

H O S P I T A L S

N E E D L E E X C H A N G E S

• Average of 12 people per monthentering treatment from needle exchanges across state.

O U T R E A C H S E R V I C E S

• Casey’s Law

• Jail Ministry

• Street Ministry

• Court Systems

• Homeless Shelters

• Health Departments

• Domestic Violence Shelters

Meeting people in their time of need

G E N E R A L M A I N T E N A N C E I N T E R N S H I P

C H A N G I N G L I V E S W H I L E C H A N G I N G T I R E S

5 0 0 J O B S C R E A T E D

• 50% are in recovery

• 33% are ARC graduates

Addiction Recovery Care is being selected to be studied as a national best practice for taking those with substance use

disorder from addiction to employment. This study is through Health and Human Services, MDRC and Abt Associates.

D R U G O V E R D O S E R A T E S P E R 1 0 0 K T H E N A N D N O W

2008-2012

Source: NORC/USDA Drug Overdose Deaths in the U.S.https://opioidmisusetool.norc.org/#

2013-2017

Before Access to Treatment After Access to Treatment

O N T H E H O R I Z O N

• Hospitality and Restaurant Management Certificate

• Intake Specialist

• Billing and Coding

• Medical Receptionist

• Information Technology Certificate

• Customer Support

E M E R G I N G L E A D E R S T R A I N I N G P R O G R A M

• Six month leadership and culture training

• Raising up future leaders from within the company• Ensures company culture is passed down

to the new generation of leaders

• Classes cover The Serving Leader, John Maxwell, Stewardship, and Organizational Overview

• Healthcare Manager training program coming soon!

A R C ’ S M I S S I O NTo have peace in knowing that we have done all that we can to provide world-class, holistic care to those struggling with addiction by creating opportunities for each person served, employee, and stakeholder to discover their God-given destiny.

H O W T O S C H E D U L E A B E D

• Call (606) 638-0938 • Text (606) 547-4633• Chat at www.arccenters.com• Email intake@arccenters.com

24/7 Intake Department

Greg Corby-LeeHarm Reduction Strategist

University of Kentucky (KIRP/HRI)

Syringe Services Programs in Kentucky

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Faculty DisclosuresNeither my spouse nor I have any relevant financial relationships to content discussed today.

Practice Gaps/Educational Needs• Nearly half of the communities in Kentucky at high risk of an HIV/HCV

outbreak among people who inject drugs have not yet set up a local syringe services program.

• People often have the wrong or incomplete understanding of what syringe services programs are about.

• Provide education on the multiple benefits of syringe services programs.• Provide an understanding on the principles of harm reduction.

GAPS

NEEDS

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ObjectivesUpon completion of this activity, participants will be able to:• Articulate the benefits of syringe services

programs.• Generalize the six Principles of Harm Reduction.

Expected Outcome• Increase understanding and acceptance of syringe

services programs. Establish programs where needed.• Involve people who inject drugs in the development of

syringe services programs, and adhere to the Principles of Harm Reduction.

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Benefits of Syringe Services Program

REDUCE spread of infections

Cases of HIV among People Who Inject Drugs dropped by 70%, saving DC $46 million since 2008.

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Benefits of Syringe Services Program

REDUCE spread of infections

REDUCE taxes

5% 6% 7% 8% 9% 10%Source: amfAR October 2012

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Benefits of Syringe Services Program

REDUCE spread of infections

REDUCE overdoses

REDUCE taxes

Unadjusted unintentional opioid related overdose death rates in 19 communities with no, low, and high enrollment in overdose education and nasal naloxone distribution program in Massachusetts, 2002-09SOURCE: BMJ 2013;346:f174

• Understand your tolerance and be aware of when it might be lower (for example, when you have not been using for a while).

• Avoid mixing drugs, and mixing drugs and alcohol.• Recognize that medications prescribed by a doctor

may interact with street drugs and cause an overdose.

• Take care of your health: eat well, drink plenty of water, and sleep.

• If you have a new dealer or unfamiliar supply, use a small amount at first to see how strong it is.

• Avoid using alone: if you overdose, you want someone around to help.

• You’re less likely to overdose from snorting or smoking drugs than injecting them

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Benefits of Syringe Services Program

REDUCE spread of infections

DO NOT INCREASE drug use

REDUCE overdoses

REDUCE taxes

Dr. Joycelyn Elders US Surgeon General (1993-1994) “Our best scientific research shows that needle exchange programs do not increase drug use, but do reduce the spread of HIV…”

Dr. David SatcherUS Surgeon General (1998-2002)Syringe exchange is “…an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.”

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Benefits of Syringe Services Program

REDUCE spread of infections

DO NOT INCREASE drug use

DO NOT INCREASE crime

REDUCE overdoses

REDUCE taxes

(Am J Public Health. 2000;90:1933–1936)

Over the study period, increases in category-specific arrests in program and nonprogram areas, respectively, were as follows:

Type of arrest increases SSP area Non-SSP area

Drug possession 17.7% 13.4%

Economically motivated offenses 0.0% 20.7%

Resistance to police authority 0.0% 5.3%

Violent offenses 7.2% 8.0%

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Benefits of Syringe Services Program

REDUCE spread of infections

DO NOT INCREASE drug use

DO NOT INCREASE crimeINCREASE community safety

REDUCE overdoses

REDUCE taxes

Studies demonstrate that the availability of SSPs in communities results in increased safe disposal of used syringes. For instance, in Portland, Oregon, the number of improperly discarded syringes dropped by almost two-thirds after the implementation of an SSP. In 2000, approximately 3.5 million syringes were recovered in San Francisco and safely disposed of as infectious waste.Source: amfAR Public Safety, Law Enforcement, and Syringe Exchange, March 2013

1111

Benefits of Syringe Services Program

REDUCE spread of infections

DO NOT INCREASE drug use

DO NOT INCREASE crimeINCREASE community safety

INCREASE first-responder safety

REDUCE overdoses

REDUCE taxes

—Bob Scott, former Captain,Sheriff’s Office, Macon County, N.C.

“Syringe exchange programs take dirty needles off the streets and increase the safety of our police officers. Indeed, these programs have decreased needle stick injuries to police by 66 percent.”

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Benefits of Syringe Services Program

REDUCE spread of infections

DO NOT INCREASE drug use

DO NOT INCREASE crimeINCREASE community safety

INCREASE first-responder safetyCONNECT more people to treatment

REDUCE overdoses

REDUCE taxes

Dr. Regina Benjamin (US Surgeon General 2009-2013) Syringe exchange programs are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that SEPs also promote entry and retention into treatment.

Dr. Vivek Murthy (US Surgeon General 2014-2017) Syringe exchanges and harm reduction helps break down the stigma associated with addiction and drug use. In turn, more people are likely to seek help.

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Overview

Injecting drugs can result in costly life-threatening infections and overdose deaths … but it doesn’t have to be this way.

Given the knowledge, and the tools, PWID can be safer.

Dead people do not recover.

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Links to Sources used in presentationSlide4) SSP Map (American Foundation for AIDS Research, 2014):

https://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/2014-SSP-Map-7-17-14.pdfHIV/HCV Outbreak Vulnerable Counties (CDC) https://www.cdc.gov/pwid/vulnerable-counties-data.html

5) HIV/HCV Outbreak Vulnerable Counties (CDC) https://www.cdc.gov/pwid/vulnerable-counties-data.htmlKentucky Syringe Exchange Programs (Kentucky Cabinet for Health and Family Services) https://chfs.ky.gov/agencies/dph/dehp/hab/Pages/kyseps.aspx

7) https://www.amfar.org/articles/around-the-world/treatasia/2012/investing-in-syringe-exchange-results-in-future-cost-savings/8) https://www.bmj.com/content/346/bmj.f1749) http://www.thebody.com/content/art13347.html

http://www.drugpolicy.org/news/2004/09/overwhelming-evidence-shows-sterile-syringe-access-reduces-spread-hiv-hepatitis-c-and-d10) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446444/pdf/11111271.pdf (Am J Public Health. 2000;90:1933–1936)11) https://www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/fact%20sheet%20Syringe%20Exchange%20031413.pdf

https://pdfs.semanticscholar.org/ca21/0886d0f501085029d59a65e920a99d109200.pdf Am J Epidemiol. 1997 Apr 15;145(8):730-712) Bob Scott on SSP public safety: https://vimeo.com/3013935713) https://www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/fact%20sheet%20Syringe%20Exchange%20031413.pdf

https://www.poz.com/article/us-endorses-harm-reduction

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