State Responses to
Rx Drug and Heroin Abuse
Presenters:
• Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy
...
Disclosures
Maggie Hart Stebbins; Michael Landen, MD,
MPH; Ralph Orr; Dean Wright, RPh, PMP; and
Mark D. Birdwhistell, MPA...
Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relation...
Learning Objectives
1. Outline how Virginia’s new Health and Criminal
Justice Data Committee is designed to respond
to con...
Advocacy Track:
State Responses to Rx Drug and
Heroin Abuse
Dean Wright, RPh
Director of Arizona’s Controlled
Substances P...
Disclosure statement:
Dean Wright, RPh, has disclosed no
relevant, real or apparent personal
or professional financial
rel...
Learning Objective:
Explain Arizona’s state-wide
prescriber report cards.
The Strategies
1. Reduce Illicit Acquisition and Diversion of Rx Drugs
2. Educate Prescribers and Pharmacists about “Rx Dr...
Strategy #1: Reduce Acquisition
• Proper Disposal
• Permanent drop boxes
• Take-back events
• Community education and awar...
Specialty CountOfSpecialty
Pathology 21
Hospice 24
Addiction Medicine 33
Preventive Medicine 56
Physical Medicine & Rehab ...
Arizona State Board of Pharmacy
Controlled Substances Prescription Monitoring Program
1616 W. Adams, Suite 120
Phoenix, AZ...
CSPMP Report Cards
Report cards for the 3rd Quarter of 2015
1543 mailed on 12/28/15
8429 emailed on 1/4/16 to 1/5/16
So fa...
CSPMP Report Cards
Next set of report cards for the 4th
Quarter 2015 will go out the 1st week
of March 2016.
QUESTIONS?
Arizona State Board of Pharmacy
Web page: https://pharmacypmp.az.gov
Dean Wright, CSPMP Director
Arizona State ...
Advocacy Track: State Responses
to Rx Drug and Heroin Abuse
Ralph Orr
Director, Virginia’s Prescription
Monitoring Program
Disclosure Statement
• Ralph Orr has disclosed no relevant, real or
apparent personal or professional financial
relationsh...
Objectives
• Discuss recommendations of the Virginia
Governor’s Task Force on Prescription Drug
and Heroin Abuse
• Outline...
Task Force
Establishment & Structure
19
• Healthy VA Plan: Executive Order 29
• Co-chaired by Secretary Hazel & Secretary ...
Recommendations: Major Themes
20
Access to Naloxone
Maximization of
Prescription
Monitoring Program
Provider education
and...
Maximizing the
PMP
Using the Prescription
Monitoring Program to its
maximum benefit to decrease
overdose and promote legit...
Drug Courts & Law
Enforcement Support
“We cannot arrest
our way out of
this problem.”
22
Provider education and proper
pre...
Continuing Action
23
Leadership on
cross-
secretariat
coordination
efforts
Engagement
from agencies
(VDH, DBHDS,
DHP, DCJS...
PMP
Med Examiner
ED
Data
State Police
Forensics
Corrections
Juvenile Justice
Workforce
data
PROBLEM: LACK OF COORDINATED
A...
HEALTH AND CRIMINAL JUSTICE DATA
COMMITTEE: PROVIDES MECHANISM
FOR COORDINATED ANALYSIS
Virginia Prescription Opioid Data
Comparing Hospitalizations to Fatal Overdoses
0
100
200
300
400
500
600
700
800
900
1000...
Virginia Heroin Data
Comparing Hospitalizations to Fatal Overdoses
0
50
100
150
200
250
300
350
FY2008 FY2009 FY2010 FY201...
Submissions to Virginia Department of Forensic
Science: Prescription Opioids and Heroin
0
1,000
2,000
3,000
4,000
5,000
6,...
Opioids Prescribed in Virginia
Six Drugs Represent 90% of Opioid Prescriptions in First
Half of 2015
0%
10%
20%
30%
40%
50...
TASK FORCE WEBPAGE:
Virginia Governor's Task Force on Prescription Drug and
Heroin Abuse
• CONTACT INFORMATION
– Phone #: ...
Advocacy Track: State Response to
Rx Drug and Heroin Abuse
Michael Landen
State Epidemiologist
New Mexico Department of He...
Disclosure
Michael Landen, MD, MPH, has disclosed no
relevant, real or apparent personal or
professional financial relatio...
Approved Learning Objectives
Describe New Mexico’s model for stakeholder
collaboration to reduce opioid overdose deaths.
0
5
10
15
20
25
30
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
Deathsper100,000persons
Year
Drug Over...
Drug Overdose Death Rates
Leading States, U.S., 2014
Rank State Deaths per 100,000
1 West Virginia 35.5
2 New Mexico 27.3
...
Drug Overdose Death Rates for Selected Drugs, NM, 1990-2014
0
2
4
6
8
10
12
14
1990
1991
1992
1993
1994
1995
1996
1997
199...
Drug Overdose Death Rates by Census
Tract Poverty Level*
New Mexico, 2009-2013
15.6
16.8
23.0
27.1
29.9
23.8
0
5
10
15
20
...
0.0
5.0
10.0
15.0
20.0
25.0
30.0
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
Overdosedeathsper100,000pop
MorphineEquivale...
New Mexico Mechanisms - 2011
• 7 licensing boards for each controlled
substance prescribers profession
• PMP in Board of P...
2012 Legislative Session
• 3 bills introduced
– Opioid Prescribing Limits and PMP bills failed
• Pain Relief Act revised
–...
Council
• Meets every 1- 2 months
• Annual recommendations to Governor
• Voting members include Department of
Health, lice...
Improving Prescribing
• Council recommended PMP move from data
within 7 days to within one day - implemented
• Reviewed li...
Percent of Patients with No PMP Review by Opioid Use
Category, NM, 2014
93
81
56
42
31
0
20
40
60
80
100
1 prescription < ...
Naloxone Access
• Council recommended Naloxone for Medicaid
formulary
• Brought Medicaid managed care
organizations togeth...
Naloxone Distribution and Reported Reversals,
NMDOH Programs, NM, 2010-2014
Source: NM DOH Harm Reduction Program and Co-P...
Pharmacist Prescriptive Authority
• Based on 2002 law which provided pharmacists prescriptive
authority
– The Board of Pha...
Medicaid Claims for Naloxone from Outpatient
Pharmacies, NM January 2013- June 2015
Source: NM HSD Medicaid Claims; NM PMP...
Treatment Availability
• Chronic pain patient presentations
– Chronic pain survey process developing
• Buprenorphine barri...
0 2000 4000 6000 8000 10000 12000
Methadone
Buprenorphine/Naloxone
Heroin
Prescription Pain Relievers
Treatment
Abuseor
De...
2016 Legislative Session
• Naloxone
– Standing order and storage bills passed
– Special meeting of council to implement st...
Recommendations
• Develop and maintain a state-level overdose
prevention policy group
– Transparency particularly around l...
Advocacy Track: State Response to
Rx Drug and Heroin Abuse
Disclosure
Maggie Hart Stebbins, Bernalillo County
Commissioner, has disclosed no relevant, real or
apparent personal or p...
Approved Learning Objectives
Describe New Mexico’s model for stakeholder
collaboration to reduce opioid overdose deaths.
Maggie Hart Stebbins, Bernalillo
County Commissioner
• Joined the Bernalillo County Commission in
2009.
• Actively engaged...
Bernalillo County
• Located along the
middle Rio Grande of
New Mexico
• Largest population in
the State of New
Mexico, wit...
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20...
Source: New York Times: How the Epidemic of Drug Overdose Deaths Ripples Across America. January 19, 2016
New Mexico Overd...
Bernalillo County Metropolitan Detention Center (MDC)
• Bernalillo County is responsible for the operations and maintenanc...
Healing Addiction in
Our Community (HAC)
• Formed in April 2010
• To educate, advocate,
raise awareness
• 2014 opened Sere...
• Made up of community members, health and social service providers,
educators, and other private and public employees tha...
bchealthcouncil.org
Collective Impact Initiatives
BERNALILLO COUNTY
OPIOID ACCOUNTABILITY INITIATIVE
“Turning the Curve on...
SUMMIT PLANNING COMMITTEE
Focused on identifying recommendations, indicators,
panelists and format for first Summit , 20 m...
SUMMIT
PLANNING
COMMITTEE
SUMMIT #1
September
19, 2013
IMPLEMENTATION
TEAMS
PRIMARY
PREVENTION
NARCAN
TREATMENT
LAW
ENFORC...
Four Implementation Teams with
volunteers from Summit - plus others – have
met monthly to:
 strategize about recommendati...
PRIMARY PREVENTION
IMPLEMENTATION TEAM
What works or would work to "turn the curve" on this problem?
RECOMMENDATIONS FOR A...
What would work to "turn the curve" on this problem?
RECOMMENDATIONS FOR ACTION
•Distribute naloxone to persons being rele...
TREATMENT
IMPLEMENTATION TEAM
What works or would work to "turn the curve" on this problem?
RECOMMENDATIONS FOR ACTION
• I...
TREATMENT continued
RECOMMENDATIONS FOR ACTION
• Expand number and capacity of residential and inpatient programs
o Work w...
TREATMENT continued
RECOMMENDATIONS FOR ACTION
• Develop a comprehensive inventory/mapping of current treatment services t...
LAW ENFORCEMENT/CRIMINAL JUSTICE
IMPLEMENTATION TEAM
What works or would work to "turn the curve" on this problem?
RECOMME...
LAW ENFORCEMENT/CRIMINAL JUSTICE
continued
RECOMMENDATIONS FOR ACTION
• For persons already under medication-assisted trea...
WHERE ARE WE NOW?
• Continued rise is opioid deaths in NM and Bernalillo County
• Numerous tragic encounters between law e...
WHERE ARE WE NOW?
Cont’d
Treatment -- Managing prescription opioids:
 Medicaid expansion has started targeting enrollment...
WHERE ARE WE NOW?
Cont’d
Naloxone:
 NM pharmacists can have prescription authority for naloxone.
 2016 Legislative Sessi...
WHERE ARE WE NOW?
Cont’dPrevention:
• Focus on reducing supply of prescription opioids through take-backs, and control of
...
IMPLEMENTATION
TEAMS
PRIMARY
PREVENTION
NARCAN
TREATMENT
LAW
ENFORCEMENT/
CRIMINAL JUSTICE
ACTION
TEAM
C
O
O
R
D
I
N
A
T
I...
New Mexico Heroin and Opioid
Prevention and Education
(HOPE) Initiative
• Launched January 2015
• Collaboration between Ne...
Challenges Ahead
• Educating elected officials and government bureaucracies
• Poor drug treatment infrastructure, personne...
State Responses to
Rx Drug and Heroin Abuse
Presenters:
• Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy
...
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Rx16 adv tues_200_1_wright_2orr_3landen_4hartstebbins
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State Responses to Rx Drug and Heroin Abuse

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  1. 1. State Responses to Rx Drug and Heroin Abuse Presenters: • Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy • Ralph Orr, Director, Virginia Prescription Monitoring Program, Virginia Department of Health Professions • Michael Landen, MD, MPH, State Epidemiologist, New Mexico Department of Health • Maggie Hart Stebbins, County Commissioner, Bernalillo (NM) Board of Commissioners Advocacy Track Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare
  2. 2. Disclosures Maggie Hart Stebbins; Michael Landen, MD, MPH; Ralph Orr; Dean Wright, RPh, PMP; and Mark D. Birdwhistell, MPA, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
  3. 3. Disclosures • All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months. • The following planners/managers have the following to disclose: – John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest: Starfish Health (spouse) – Robert DuPont – Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center
  4. 4. Learning Objectives 1. Outline how Virginia’s new Health and Criminal Justice Data Committee is designed to respond to concerns before they become crises. 2. Explain Arizona’s state-wide prescriber report cards. 3. Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths. 4. Provide accurate and appropriate counsel as part of the treatment team.
  5. 5. Advocacy Track: State Responses to Rx Drug and Heroin Abuse Dean Wright, RPh Director of Arizona’s Controlled Substances Prescription Monitoring Program
  6. 6. Disclosure statement: Dean Wright, RPh, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
  7. 7. Learning Objective: Explain Arizona’s state-wide prescriber report cards.
  8. 8. The Strategies 1. Reduce Illicit Acquisition and Diversion of Rx Drugs 2. Educate Prescribers and Pharmacists about “Rx Drug Best Practices” and emphasize responsible prescribing 3. Enhance Rx Drug Practice and Policies in Law Enforcement 4. Increase Public Awareness about the Risks of Rx Drug Misuse 5. Build Resilience in Children and Adults
  9. 9. Strategy #1: Reduce Acquisition • Proper Disposal • Permanent drop boxes • Take-back events • Community education and awareness • Proper Storage • Community education and awareness • Increase the use of the PDMP • More law enforcement, prescribers and dispensers signed up and using the PDMP • A data feedback system for prescribers to self-monitor prescribing practices
  10. 10. Specialty CountOfSpecialty Pathology 21 Hospice 24 Addiction Medicine 33 Preventive Medicine 56 Physical Medicine & Rehab 104 Optometry 125 Podiatry-Surgical 130 Podiatry-General 141 Dentists-Orthodontics 145 Otolaryngology 148 Dentists-Surgical 155 Pain Medicine 164 Urology 167 Oncology 202 Radiology 285 Anesthesiology 305 Neurology 362 Naturopath 375 OBGYN 847 Psychiatry 1193 Pediatrics 1204 Other PA-APN 1426 Surgery 1519 Emergency Medicine 1543 Dentists-General 2709 Internal Medicine 4674 Family Medicine 5483 23552
  11. 11. Arizona State Board of Pharmacy Controlled Substances Prescription Monitoring Program 1616 W. Adams, Suite 120 Phoenix, AZ 85007 February 18, 2016 «Prescriber_Name» «Degree» «Address» «City», «State» «Zip» Dear «Prescriber_Name» «Degree»: The Arizona State Board of Pharmacy, in collaboration with the Arizona Substance Abuse Partnership, is participating in an initiative to address the growing concern over prescription drug misuse and abuse in Arizona. The Rx Initiative involves stakeholders from the Arizona Department of Health Services, the Arizona Criminal Justice Commission, the Governor’s Office of Youth, Faith and Family, and local substance abuse prevention coalitions. A major focus of the Rx Initiative involves promoting responsible prescribing and dispensing practices among medical professionals in Arizona. In an effort to help you monitor your own prescribing habits, please find an attached report card that details your prescribing patterns related to the types of prescription medications of interest to the Initiative. These medications were chosen based on data that identified them as the most commonly prescribed and the most commonly misused by youth and adults. Additionally, these drugs account for the majority of drug-related Emergency Department visits and poisoning deaths in Arizona. The data provided by the report card is for your information only. Please take a moment to review the report card to compare your prescribing practices to those of your colleagues, and help us promote responsible prescribing in Arizona. If you are an outlier (i.e., prescribing at least 1 Standard Deviation above the mean compared to your colleagues), we encourage you to consider if your prescribing practices follow best practice guidelines for your medical specialty. You can find the Arizona Opioid Prescibing Guidelines on the Arizona Department of Health Services website at http://azdhs.gov/audiences/clinicians/index.php#guidelines- recommendations-rx-guidelines. We also encourage you to educate your patients about the risks of Rx drug misuse and proper storage and disposal methods. Locations of permanent drop boxes can be found at www.dumpthedrugsaz.org . If you have not yet done so, please go to the website below to sign up for access to the Prescription Drug Monitoring Program (PDMP) database: https://pharmacypmp.az.gov/. The PDMP is an essential tool for checking your patient’s medication history, for monitoring their drug therapy, and for minimizing misuse. If you have any questions, please do not hesitate to call the Arizona State Board of Pharmacy at 602.771.2748 or 602.771.2732. ______________________________ ______________________________ Debbie Moak John A Blackburn Jr Arizona Substance Abuse Partnership Executive Director, The Governor’s Office of Youth, Faith and Family Arizona Criminal Justice Commission ______________________________ ______________________________ Cara M. Christ, MD Dean Wright Director, Monitoring Program Director, Arizona Department of Health Services Arizona State Board of Pharmacy
  12. 12. CSPMP Report Cards Report cards for the 3rd Quarter of 2015 1543 mailed on 12/28/15 8429 emailed on 1/4/16 to 1/5/16 So far: 66 returned envelopes 935 bounced emails
  13. 13. CSPMP Report Cards Next set of report cards for the 4th Quarter 2015 will go out the 1st week of March 2016.
  14. 14. QUESTIONS? Arizona State Board of Pharmacy Web page: https://pharmacypmp.az.gov Dean Wright, CSPMP Director Arizona State Board of Pharmacy 1616 W. Adams, Suite 120 P.O. Box 18520 Phoenix, AZ 85005 602-771-2744 Fax: 602-771-2748 dwright@azpharmacy.gov
  15. 15. Advocacy Track: State Responses to Rx Drug and Heroin Abuse Ralph Orr Director, Virginia’s Prescription Monitoring Program
  16. 16. Disclosure Statement • Ralph Orr has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.”
  17. 17. Objectives • Discuss recommendations of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse • Outline how Virginia’s new Health and Criminal Justice Data Committee is designed to respond to concerns before they become crises.
  18. 18. Task Force Establishment & Structure 19 • Healthy VA Plan: Executive Order 29 • Co-chaired by Secretary Hazel & Secretary Moran • Five meetings between November 2014 and September 2015, resulting in 51 recommendations • 32 members, 5 workgroups  Education  Treatment  Storage & Disposal  Data & Monitoring  Law Enforcement 2 Co- chairs 32 multi- disciplinary, bipartisan members 5 workgroups
  19. 19. Recommendations: Major Themes 20 Access to Naloxone Maximization of Prescription Monitoring Program Provider education and proper prescribing/dispensing Access to and availability of treatment Drug courts and incarceration-based programs; further support for law enforcement Information and Data
  20. 20. Maximizing the PMP Using the Prescription Monitoring Program to its maximum benefit to decrease overdose and promote legitimate use of controlled substances. 21 Access to and Availability of Treatment Treating opioid and heroin addiction requires a complex and individualized set of services, including Medically Assisted Treatment, group and individual counseling, and peer supports.
  21. 21. Drug Courts & Law Enforcement Support “We cannot arrest our way out of this problem.” 22 Provider education and proper prescribing/dispensing • Students: – Medical School curricula – Social Work curricula • Medical residents: – Loan forgiveness for Addiction Medicine residency program – Grand Rounds inclusion • Practicing Providers: – Mandate and/or incentivize Continuing Medical Education (CME) for current providers
  22. 22. Continuing Action 23 Leadership on cross- secretariat coordination efforts Engagement from agencies (VDH, DBHDS, DHP, DCJS) and legislature Health and Criminal Justice Data Committee Development of Website
  23. 23. PMP Med Examiner ED Data State Police Forensics Corrections Juvenile Justice Workforce data PROBLEM: LACK OF COORDINATED ANALYSIS OF DATA
  24. 24. HEALTH AND CRIMINAL JUSTICE DATA COMMITTEE: PROVIDES MECHANISM FOR COORDINATED ANALYSIS
  25. 25. Virginia Prescription Opioid Data Comparing Hospitalizations to Fatal Overdoses 0 100 200 300 400 500 600 700 800 900 1000 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 CountofHospitalizationsandFatalOD Hospitalizations Fatal OD Data Sources: OCME Fata Drug Overdose Quarterly Report (2015 data are projected, preliminary figures); OFHS response to data request 12/30/2015.
  26. 26. Virginia Heroin Data Comparing Hospitalizations to Fatal Overdoses 0 50 100 150 200 250 300 350 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 CountofHospitalizationsandFatalOD Hospitalizations Fatal OD Data Sources: OCME Fatal Drug Overdose Quarterly Report (2015 data are projected, preliminary figures); OFHS response to data request 12/30/2015
  27. 27. Submissions to Virginia Department of Forensic Science: Prescription Opioids and Heroin 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 CY2002 CY2003 CY2004 CY2005 CY2006 CY2007 CY2008 CY2009 CY2010 CY2011 CY2012 CY2013 CY2014 CasesSubmitted RxOpioids Heroin Data Source: DFS monthly submission to the National Forensic Laboratory Information System (NFLIS), shared with DCJS
  28. 28. Opioids Prescribed in Virginia Six Drugs Represent 90% of Opioid Prescriptions in First Half of 2015 0% 10% 20% 30% 40% 50% 60% Hydrocone SA Oxycodone SA Tramadol SA Buprenorphine Codeine Hydromorphone 2010JanJunPct 2011JanJunPct 2012JanJunPct 2013JanJunPct 2014JanJunPct 2015JanJunPct Data Sources: Brandeis University report, 11/23/2015. That report used Virginia Prescription Monitoring Program database as its source.
  29. 29. TASK FORCE WEBPAGE: Virginia Governor's Task Force on Prescription Drug and Heroin Abuse • CONTACT INFORMATION – Phone #: 804-367-4566 – Fax 804-527-4470 – Email- ralph.orr@dhp.virginia.gov – Virginia's Prescription Monitoring Program
  30. 30. Advocacy Track: State Response to Rx Drug and Heroin Abuse Michael Landen State Epidemiologist New Mexico Department of Health
  31. 31. Disclosure Michael Landen, MD, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
  32. 32. Approved Learning Objectives Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths.
  33. 33. 0 5 10 15 20 25 30 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 Deathsper100,000persons Year Drug Overdose Death Rates New Mexico and United States, 1990-2014 New Mexico United States Rates are age adjusted to the US 2000 standard population Source: United States (CDC Wonder); New Mexico (NMDOH BVRHS/SAES, 1990-1998,2014 ; NM-IBIS, 1999-2013)
  34. 34. Drug Overdose Death Rates Leading States, U.S., 2014 Rank State Deaths per 100,000 1 West Virginia 35.5 2 New Mexico 27.3 3 New Hampshire 26.2 4 Kentucky 24.7 5 Ohio 24.6 U.S. 14.7 Sources: CDC Wonder Rates are age-adjusted to the 2000 US Standard Population.
  35. 35. Drug Overdose Death Rates for Selected Drugs, NM, 1990-2014 0 2 4 6 8 10 12 14 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deathsper100,000population Heroin Prescription Opioids Methamphetamine Cocaine Sedative-hypnotics Drug categories are not mutually exclusive. Source: Office of the Medical Investigator; UNM/GPS population
  36. 36. Drug Overdose Death Rates by Census Tract Poverty Level* New Mexico, 2009-2013 15.6 16.8 23.0 27.1 29.9 23.8 0 5 10 15 20 25 30 35 Less than 5% 5 - 9.9% 10 - 19.9% 20 - 29.9% 30% - 39.9% 40% or more Deathsper100,000Population *Poverty level is the percentage of persons of all ages in the decedent’s census tract living at or below 100% of Poverty. Drug Overdose deaths are defined by ICD 10: X40-X44, X60-X64, X85, Y10-Y14. Rates have been age-adjusted to the standard U.S. 2000 population. Source: NM Vital Records and Health Statistics, U.S. Bureau of the Census, American Community Survey
  37. 37. 0.0 5.0 10.0 15.0 20.0 25.0 30.0 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Overdosedeathsper100,000pop MorphineEquivalents(kg)per10,000pop MME of Opioids Sold and Overdose Death Rates NM, 2001-2014 Morphine equivalents sold Drug OD Death Rate Buprenorphine and Methadone excluded from total morphine equivalents; Source: DEA
  38. 38. New Mexico Mechanisms - 2011 • 7 licensing boards for each controlled substance prescribers profession • PMP in Board of Pharmacy with shared access for Department of Health via regulation • Naloxone widely distributed alongside syringe exchange
  39. 39. 2012 Legislative Session • 3 bills introduced – Opioid Prescribing Limits and PMP bills failed • Pain Relief Act revised – Mandatory continuing education for prescribers – Required licensing boards to have chronic pain management rules – Established Governor’s Council on overdose prevention and pain management
  40. 40. Council • Meets every 1- 2 months • Annual recommendations to Governor • Voting members include Department of Health, licensing boards, professional associations, consumers, chronic pain patients, pain management specialists – Some licensing boards not voting members – Many others attend and participate
  41. 41. Improving Prescribing • Council recommended PMP move from data within 7 days to within one day - implemented • Reviewed licensing board chronic pain management rules • Reviewed overdose death – PMP linked data • Reviewed prescriber report cards • Reviewed quarterly prescribing measures • Recommended PMP check with each opioid Rx
  42. 42. Percent of Patients with No PMP Review by Opioid Use Category, NM, 2014 93 81 56 42 31 0 20 40 60 80 100 1 prescription < 90 days 90-180 days 180-330 days Full Time Percentofpatients 1 year Opioid Use Category Source: NM Prescription
  43. 43. Naloxone Access • Council recommended Naloxone for Medicaid formulary • Brought Medicaid managed care organizations together to work on reimbursement • Regular updates on naloxone availability including availability by community/overdose death rates • Recommended standing order and statute
  44. 44. Naloxone Distribution and Reported Reversals, NMDOH Programs, NM, 2010-2014 Source: NM DOH Harm Reduction Program and Co-Prescription Pilot Program 0 1000 2000 3000 4000 5000 6000 7000 2011 2012 2013 2014 Number Doses dispensed 0 200 400 600 800 1000 2011 2012 2013 2014 Reported Reversals
  45. 45. Pharmacist Prescriptive Authority • Based on 2002 law which provided pharmacists prescriptive authority – The Board of Pharmacy adopts regulations and protocols governing certification for specified “dangerous drug therapies” • Vaccinations, emergency contraception, tobacco cessation drugs, and tuberculosis testing are allowed by certification • Naloxone certification was established by regulation in 2014 – Training is provided by the NM Pharmacist’s Association and certification is maintained by completing 2 hours of CE every 2 years – About 180 pharmacists have been certified to date • Reporting system in place – About 200 reports of persons prescribed naloxone by pharmacists
  46. 46. Medicaid Claims for Naloxone from Outpatient Pharmacies, NM January 2013- June 2015 Source: NM HSD Medicaid Claims; NM PMP 0 1 17 66 100 0 20 40 60 80 100 120 Jan-Jun 2013 Jul-Dec 2013 Jan-Jun 2014 Jul-Dec 2014 Jan-Jun 2015 Numberofclaims Six month time period
  47. 47. Treatment Availability • Chronic pain patient presentations – Chronic pain survey process developing • Buprenorphine barriers and access reviewed • Recommended end to Medicaid pre- authorization • Tracked opioid treatment need and actual use disparity
  48. 48. 0 2000 4000 6000 8000 10000 12000 Methadone Buprenorphine/Naloxone Heroin Prescription Pain Relievers Treatment Abuseor Dependence Number of People Estimated Number of People with Abuse/Dependence on Opioids and Numbers of People in Treatment, NM, 2014 Source: NM Treatment Need Estimates, NMDOH; NM Prescription Monitoring Program; NM Behavioral Health
  49. 49. 2016 Legislative Session • Naloxone – Standing order and storage bills passed – Special meeting of council to implement standing order process • Prescription Monitoring Program – Floated every check for every opioid Rx, – initial bill had check for initial and q 3 month – ended up with 4 day short prescription exception – Council will lead joint process to revise 7 licensing board chronic pain management rules
  50. 50. Recommendations • Develop and maintain a state-level overdose prevention policy group – Transparency particularly around legislation – Hope to add a smaller, parallel state agency group • Develop indicators for the group with regular data updates • Establish a regular cycle for developing recommendations • Don’t get complacent – the overdose epidemic and interventions constantly change
  51. 51. Advocacy Track: State Response to Rx Drug and Heroin Abuse
  52. 52. Disclosure Maggie Hart Stebbins, Bernalillo County Commissioner, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
  53. 53. Approved Learning Objectives Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths.
  54. 54. Maggie Hart Stebbins, Bernalillo County Commissioner • Joined the Bernalillo County Commission in 2009. • Actively engaged in efforts related to behavioral health, including: – Bernalillo County Opioid Accountability Initiative. – Bernalillo County Criminal Justice Review Commission – Bernalillo County Behavioral Health Initiative
  55. 55. Bernalillo County • Located along the middle Rio Grande of New Mexico • Largest population in the State of New Mexico, with more than 675,000 residents • Includes the City of Albuquerque Images courtesy of marblestreetstudio.com
  56. 56. 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 Bernalillo Co. 11. 11. 14. 15. 15. 16. 17. 15. 23. 20. 20. 20. 23. 24. 19. 26. 26. 27. 34. 26. 26. 29. 28. 22. 28. New Mexico 7.6 7.8 8.9 10. 9.6 11. 11. 11. 15. 15. 15. 14. 16. 19. 16. 19. 21. 22. 26. 21. 23. 25. 24. 21. 26. 0 5 10 15 20 25 30 35 40 Deathsper100,000pop Total Overdose Death Rate, Bernalillo County and New Mexico, 1990-2014 Bernalillo Co. New Mexico Rates age adjusted to the US 2000 standard population Source: Bureau of Vital Records and Health Statistics, UNM/GPS population est.
  57. 57. Source: New York Times: How the Epidemic of Drug Overdose Deaths Ripples Across America. January 19, 2016 New Mexico Overdose Deaths, 2003-2014
  58. 58. Bernalillo County Metropolitan Detention Center (MDC) • Bernalillo County is responsible for the operations and maintenance of the MDC, which comes at a cost of $84M for fiscal year 2016 and represents 30% of the County’s General Fund budget of $281M. • Under court order to reduce jail population, which in 2012 was at 2800, and today is at approximately 1400, a 50% reduction. • Accomplished as result of Bernalillo County Criminal Justice Review Commission, and Bernalillo County Adult Detention Reform team. • Their efforts have highlighted the need for increased and better coordinated behavioral health services in our community, along with judicial reforms to make the system more efficient. • 60% of MDC inmates with mental health, substance use or co-occurring • disorders • MDC is the largest behavioral health care provider in NM.
  59. 59. Healing Addiction in Our Community (HAC) • Formed in April 2010 • To educate, advocate, raise awareness • 2014 opened Serenity Mesa Youth Recovery Center, providing residential rehabilitation services to youth ages 14-21.
  60. 60. • Made up of community members, health and social service providers, educators, and other private and public employees that serve County residents • History of bringing people together to explore public health concerns • Until last year was an official part of BernCo Government, today is it’s own non-profit. • Experienced and highly skilled facilitator, Marsha McMurry Avila, serves as the Executive Director.
  61. 61. bchealthcouncil.org Collective Impact Initiatives BERNALILLO COUNTY OPIOID ACCOUNTABILITY INITIATIVE “Turning the Curve on Opioid Abuse in Bernalillo County”
  62. 62. SUMMIT PLANNING COMMITTEE Focused on identifying recommendations, indicators, panelists and format for first Summit , 20 multi-sectoral members representing: • Advocates, community activists, drug policy analysts, data analysts • Albuquerque Health Care for the Homeless • Bernalillo County Community Health Council • Bernalillo County Department of Substance Abuse Programs/MATS • Bernalillo County Urban Health Extension • City of Albuquerque Division of Health & Human Services • Heroin Awareness Committee (Healing Addiction in Our Community) • Molina Healthcare • New Mexico Department of Health – Health Promotion • New Mexico Department of Health – Office of Injury Prevention • New Mexico Department of Health – Turquoise Lodge • Presbyterian Healthcare Services • UNM Prevention Research Center for Education Policy Research • UNM Preventive Medicine • UNM Urban Health Partners – Pathways to a Health Bernalillo County • UNM Center for Alcoholism, Substance Abuse & Addictions (CASAA) • UNM RWJF Health Policy Center
  63. 63. SUMMIT PLANNING COMMITTEE SUMMIT #1 September 19, 2013 IMPLEMENTATION TEAMS PRIMARY PREVENTION NARCAN TREATMENT LAW ENFORCEMENT/ CRIMINAL JUSTICE COORDINATING COMMITTEE INTERIM UPDATE MEETING June 2014 SUMMIT #2 January 2015 BERNALILLO COUNTY OPIOID ACCOUNTABILITY INITIATIVE TIMELINE (Fall 2012 – Winter 2015) August 2012 -------------September 2013 ------------------>December 2013 ---------------------------->June 2014-->Fall 2014
  64. 64. Four Implementation Teams with volunteers from Summit - plus others – have met monthly to:  strategize about recommendations for their specific area, including identifying decision- makers who are key players to bring to the table  select indicator(s) as target to measure progress toward desired outcome(s)  inventory available services/gaps in their area, identifying need for additional resources  provide ideas for next Summit
  65. 65. PRIMARY PREVENTION IMPLEMENTATION TEAM What works or would work to "turn the curve" on this problem? RECOMMENDATIONS FOR ACTION • Expand access to drug counseling and prevention services for high school and middle school students including appropriate referrals, working to gain reimbursement coverage from Medicaid • Support policies to expand evidence-based early childhood support programs, including home visiting focusing first on low-income families • For pain control, promote evidence-based alternatives for Rx opioids, such as chiropractic or other physical medicine • Reduce supply of Rx opioid pain medication by increasing access to and usage of Prescription Monitoring Program database AND promoting prescribing guidelines to limit over-prescription of opioids
  66. 66. What would work to "turn the curve" on this problem? RECOMMENDATIONS FOR ACTION •Distribute naloxone to persons being released from MDC and their families •Restructure P&P policies to allow for parolees to have naloxone rescue kits while on parole •Assure all police officers are carrying naloxone and trained in its use •Support implementation of authorization allowing pharmacists to prescribe naloxone o Support development of MCO reimbursement mechanisms for kits and education/consultation o Assure naloxone rescue kits are stocked at all pharmacies •Advocate for all providers to co-prescribe naloxone with opioid pain meds for chronic pain management •Make naloxone and training available to agencies with outreach programs for injection drug users, treatment centers and methadone clinics •Make naloxone available at all public health offices as walk-in sites NARCAN IMPLEMENTATION TEAM Make availability of naloxone normal and universal
  67. 67. TREATMENT IMPLEMENTATION TEAM What works or would work to "turn the curve" on this problem? RECOMMENDATIONS FOR ACTION • Increase MD participation in prescribing • Continue MAT for MDC inmates already in treatment when incarcerated • Offer pre-release MAT to MDC inmates not yet in treatment • Assure access for uninsured populations, including those not eligible for coverage • Expand buprenorphine beyond detox to ongoing maintenance treatment when appropriate (Turquoise Lodge and MATS) • Address issue of drug courts excluding people on MAT • Address BHSD guidelines allowing only psychiatrists to prescribe buprenorphine and no payment for methadone • Address private insurance payment for methadone • Address VA lack of provision and payment for methadone • License mid-level practitioners to prescribe buprenorphine • (issue of federal regulations) 1. Expand access to medication-assisted treatment (MAT)
  68. 68. TREATMENT continued RECOMMENDATIONS FOR ACTION • Expand number and capacity of residential and inpatient programs o Work with Medicaid, Centennial Care MCOs and private insurance to provide coverage/ reimbursement o Assure access for uninsured populations, including those not eligible for coverage • Duration of coverage for specific levels of intervention should be flexible and tailored to patient needs • Assure identification and treatment of co-occurring disorders • Eliminate need for diagnosed co-occurring condition as a requirement for Medicaid funding of treatment of alcohol/drug dependency • Include wrap-around support services as integral part of funding for treatment services, including assistance finding housing/jobs • Identify and offer enrollment to all persons who are drug users or at risk for opioid use and are eligible for Medicaid, especially persons being released from incarceration 2. Expand full array of treatment services aligned with ASAM guidelines TREATMENT continued
  69. 69. TREATMENT continued RECOMMENDATIONS FOR ACTION • Develop a comprehensive inventory/mapping of current treatment services to determine gaps in capacity and levels of care as basis for an effective, coordinated system • Develop current, consistently updated database of services accessible to providers and community (including eligibility criteria and program capacity) • Identify opportunities for enhanced linkages among different components of the system • Develop shared measurement criteria to allow for evaluation of system linkages and accurate cost reports • Propose realignment of resources to support prioritized services in alignment with agreed-upon principles • Explore feasibility and appropriately plan for expansion of County DSAP as nucleus of a much-expanded integrated treatment system • Assure integration of MDC into treatment system linked to community providers/resources 3. Develop comprehensive and coordinated treatment system in Bernalillo County TREATMENT continued
  70. 70. LAW ENFORCEMENT/CRIMINAL JUSTICE IMPLEMENTATION TEAM What works or would work to "turn the curve" on this problem? RECOMMENDATIONS FOR ACTION • Increase programs offering alternatives to incarceration • Increase capacity of court system to expedite proceedings and reduce time waiting for verdicts and sentencing • Assemble stakeholders to assess feasibility of LEAD pilot by either APD or County Sheriff’s Department 1. Reduce the number of people with substance use disorders who are incarcerated
  71. 71. LAW ENFORCEMENT/CRIMINAL JUSTICE continued RECOMMENDATIONS FOR ACTION • For persons already under medication-assisted treatment (MAT) at the time of incarceration, continue methadone and Suboxone during incarceration • Conduct a pilot for pre-release induction of Suboxone and treatment with Vivitrol • Prior to or upon release, arrange for Medicaid enrollment for those eligible • Set up linkages between treatment providers and inmates • Arrange for post-release social services and medical follow-up including MAT, and distribute Narcan • Make indicated prevention programs available for incarcerated individuals with low-level substance abuse • Increase amount of discharge prescriptions from 3 days to 30 2. Provide effective treatment services for those who are incarcerated and upon release
  72. 72. WHERE ARE WE NOW? • Continued rise is opioid deaths in NM and Bernalillo County • Numerous tragic encounters between law enforcement and people struggling with substance use and mental health disorders that have heightened awareness of community service needs. • City of Albuquerque, U.S. Dept. of Justice Settlement Agreement includes several provisions that will require an investment by the City into behavioral health community resources, education and training for officers • Bernalillo County 1/8 cent GRT for Behavioral Health & BC Behavioral Health Initiative: Connect the Dots  Fill the Gaps  Leverage Resources to Maximize Impact
  73. 73. WHERE ARE WE NOW? Cont’d Treatment -- Managing prescription opioids:  Medicaid expansion has started targeting enrollment for persons at risk of addiction: example incarcerated persons.  MDC has turned around in terms of interest in helping with addiction, including maintaining MAT for persons who are on methadone at time of incarceration and active planning for drug treatment for persons being released from incarceration.  Medicaid has begun covering buprenorphine and clinician visits for medication-assisted Treatment (MAT).
  74. 74. WHERE ARE WE NOW? Cont’d Naloxone:  NM pharmacists can have prescription authority for naloxone.  2016 Legislative Session, HB 277, passed and is waiting for the Governors signature. If signed, it will allow licensed prescribers new authority to provide standing orders for unnamed persons to obtain naloxone. This will approximate OTC status naloxone without losing third party coverage for it still being a prescription drug.
  75. 75. WHERE ARE WE NOW? Cont’dPrevention: • Focus on reducing supply of prescription opioids through take-backs, and control of excess prescribing. • NM was early in establishing its PMP; now fully running with required registration. • Plans are underway to have face-to-face education encounters with prescribers who are outliers at the high end of opioid volumes. • Licensing boards requiring all prescribers to have pain management education and to participate in the PMP. • Focus on schools for education and early intervention. • Focus on early childhood intervention (Nurse Family Partnership) targeting high-risk families.
  76. 76. IMPLEMENTATION TEAMS PRIMARY PREVENTION NARCAN TREATMENT LAW ENFORCEMENT/ CRIMINAL JUSTICE ACTION TEAM C O O R D I N A T I N G C O M M A L I G N E D A C T I O N S U M M I T #2 J a n 2 0 1 5 BERNALILLO COUNTY OPIOID ACCOUNTABILITY INITIATIVE TIMELINE (as of Spring 2016) PRIMARY PREVENTION NARCAN TREATMENT LAW ENFORCEMENT/ CRIMINAL JUSTICE STRATEGY GROUPS ACTION TEAM ACTION TEAM ACTION TEAM ACTION TEAM ACTION TEAM ACTION TEAM ACTION TEAM Jan 2015 (Jan 2015 to Jan 2013) Jan 2016 Feb 2016
  77. 77. New Mexico Heroin and Opioid Prevention and Education (HOPE) Initiative • Launched January 2015 • Collaboration between New Mexico Office of U.S. Attorney’s Office, and • University of New Mexico Health Science Center, in partnership with the • Bernalillo County Opioid Accountability Initiative • Five Components: – Prevention & Education – Treatment – Law Enforcement – ReEntry – Strategic Planning
  78. 78. Challenges Ahead • Educating elected officials and government bureaucracies • Poor drug treatment infrastructure, personnel, and insurance coverage • Major issues with parity enforcement – Medicaid a particular concern • Stigma of addiction • Need to treat addiction as a chronic disease to shift from blame and punishment • The need to scale up. We have made progress in communication across stakeholders, but the requirements for scaling up to impact the indicators will require new tools to build systems of planning and collaboration. Our agencies and bureaucracies are not prepared to accept a new set of priorities that will compete for budget and disruption familiar alignments. Ultimately it will depend on strong executive leadership. • MAT-Induction at MATS & MDC? • Add Buprenephorine to MDC MAT options?
  79. 79. State Responses to Rx Drug and Heroin Abuse Presenters: • Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy • Ralph Orr, Director, Virginia Prescription Monitoring Program, Virginia Department of Health Professions • Michael Landen, MD, MPH, State Epidemiologist, New Mexico Department of Health • Maggie Hart Stebbins, County Commissioner, Bernalillo (NM) Board of Commissioners Advocacy Track Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare

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