South Central PA Opioid Awareness Coalition Forum September

South Central PA Opioid Awareness Coalition Forum September

South Central PA Opioid Awareness Coalition Forum September 15, 2017 SIGN UP TO TAKE A TWO QUESTION POLL BEFORE THE EVENT BEGINS!! Text: opioid2017 TO 22333 or go to pollev.com/opioid2017 Framing the Issue: Robert G. Shipp III, RN

Vice President Population Health Strategies 4 Framing the Issue Audience Participation Question 1 What word comes to mind when you hear

opioids? Question 2 How best can the opioid crisis be addressed? A. B. C. D. Greater community education Easier access to addiction specialists and support

Increased legislation Clearer prescription guidelines 5 Framing the Issue: Pennsylvanias Epidemic 4,642 drug overdose South Central: More than 450 deaths in our seven counties deaths in PA (2016) County Overdose death rate

37% increase from Adams: 27.6 2015 Cumberland: 24.6 13 deaths per day in Pennsylvania in 2016. Expected to be more in 2017 Dauphin:

31.3 Franklin: 26.1 Lancaster: 22.3 Lebanon: 12.0 York: 29.2 Source: DEA, 2017

PA has one of the highest state average rates in the country 6 Most Frequently Reported Overdose Deaths- 2016 In our region: #1 Heroin #2 Fentanyl 6 of our 7

counties are above the U.S. death rate Source: DEA, 2017 7 Framing the Issue: What is being done Nationally Congress passed opioid legislation Comprehensive Addiction and

Recovery Act (CARA) 21st Century Cures Act Pennsylvania received $26 million in funding Presidents Commission on Combating Drug Addiction and the Opioid Crisis President Trump proclaimed September 2017 as National Alcohol and Drug Addiction Recovery Month Congressman Tom Marino nominated as Drug Czar

Pennsylvania Established legislative and executive task forces Additional Centers of Excellence Passed a series of bills addressing this epidemic. Additional package introduced this session Began distributing drug disposal bags in hardest hit counties

Announced standing order for Naloxone at any pharmacy Released medication These interventions help, prescription guidelines but there is still more we can do 8

Framing the Issue: Why are we here today Understand the issue(s) Reduce the stigma Unify in messaging Coordinate efforts As trusted healthcare clinicians, its our duty to work

together to share best practices, increase awareness, promote education, and improve treatment, through a unified approach to combating this epidemic 9 Framing the Issue: Resources Visit the South Central PA Opioid Awareness Coalition website for additional information

www.opioidaware.org 10 11 Primary Care Chris Echterling, M.D. 12

Primary Care Prescriber education (ex. CDC Guidelines) Opioids are not first line treatment for chronic pain Opioid agreements reflecting informed shared care plan Opioid risks, securing medicine and disposal Dependency vs Addiction Monitoring for safety urine drug tests Prescription Drug Monitoring Program (PDMP)

13 Scope of the problem 76 million suffer from chronic pain, more than

diabetes, CAD and cancer combined Primary Care CDC Guidelines Opioids are not first line treatment for chronic pain Focus on function, not pain Shorter supplies for acute pain then reevaluate Monitoring for safety (urine drug tests), NOT accusing

Prescription Drug Monitoring Program (PDMP) 16 Primary Care Preventing diversion Secure your meds dont temp those who are struggling Dispose of left over meds take back boxes or trash Dependency vs Addiction

17 Primary Care Naloxone (Narcan) Prevention Survive accidental overdose (ill, child, confused) Cannot recover if you are dead (deadliest times for those with substance use disorder) Guidelines Higher dose of opioids

History of addiction/overdose You or a family member 19 Medically Assisted Treatment Adam Lake, M.D. 20

Medically Assisted Treatment Addiction is a disease The drug is not the problem Treatment works MAT works the best

21 Medically Assisted Treatment MAT = medication + therapy No clear best type of or intensity of therapy (1-4) Several options for the medication Sources: 1) Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. Journal of Addiction Medicine. 2016;10(2):91-101. doi:10.1097/ADM.0000000000000193.

2) Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD004147. DOI: 10.1002/14651858.CD004147.pub4. 3) Moore BA, Fiellin DA, Cutter CJ, Buono FD, Barry DT, Fiellin LE, O'Connor PG, Schottenfeld RS. Cognitive Behavioral Therapy Improves Treatment Outcomes for Prescription Opioid Users in Primary Care Buprenorphine Treatment. J Subst Abuse Treat. 2016 Dec;71:54-57. doi: 10.1016/j.jsat.2016.08.016. Epub 2016 Sep 2. 4) Torchalla, I., Nosen, L., Rostam, H., & Allen, P. (2012). Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: A systematic review and meta-analysis. Journal of substance abuse treatment, 42(1), 65-77. 22 Medically Assisted Treatment

Why use any medication? 3/20 died from overdoses Kakko J, Svanborg KD, Kreek MJ, Heilig M. (2003) 1-year retention and social function after buprenorphineassisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet, 361:662-668. Data from Sordo, et al. BMJ 2017;357:j1550. Visualization from plot.ly 23

Medically Assisted Treatment Methadone Buprenorphine (tablet, film, implant) Naltrexone (oral and long-acting injectable) 24 Medically Assisted Treatment Best treatment of addiction is

medication + therapy Better outcomes, fewer deaths MAT is not trading one addiction for another Many types of counseling can be effective Several options for medications 25 Chronic Pain Management

Vitaly Gordin, M.D. 26 Chronic Pain Management Medical management Interventional pain management procedures Cognitive-behavioral therapy Self directed home exercise program

Complimentary medicine Acupuncture Nutritional consult Life style changes 27 Chronic Pain Management: Medical Management Nonopioid analgesics Acetaminophen

NSAIDs Adjuvant medications Antidepressants, such as TCAs, SNRIs Anticonvulsants, such as gabapentin, pregabalin, topiramate, carbamazepine, etc. 28 Chronic Pain Management: Medical Management

Topical agents Local anesthetics Capsaicin TCAs, NSAIDs, gabapentinoids IV anesthetics: ketamine 29 Chronic Pain Management: Medical Management Opioid analgesics

CDC declared opioid induced deaths as a national epidemic Doctors wrote 72.4 opioid prescriptions per 100 persons in 2006 Decreased 4.9% annually from 2012 through 2016 Reaching a rate of 66.5 per 100 persons in 2016. A record number of drug overdose deaths occurred in 2015 52,404, prescription or illicit opioids were involved in 63.1% of these deaths

30 Chronic Pain Management: Medical Management Properly selected patients with findings on physical examination might benefit from chronic opioid therapy

Use screening tools Opioid agreements UDS (urine drug screen) Pill count PDMP Doses higher than 90 MME are not recommended, but there are exceptions

31 Chronic Pain Management: Interventional Pain Management Procedures Spinal injections Epidural steroid injections Facet joint injections Sacro-iliac joint injections Radiofrequency ablation

Neuromodulation Spinal cord stimulation Dorsal root ganglion stimulation Intrathecal therapies 32 Mental Health/Co-occurring Daniel Hornyak, M.D.

33 Mental Health/Co-occurring 45% of Americans seeking treatment have dual diagnosis Substance Abuse Disorder Mental Health Illness Substance Abuse Disorder Criteria defined in DSM 5

34 Mental Health/Co-occurring Most Americans recognize mental health is a biological problem Still dont want someone with mental illness as a neighbor or friend Many try to self medicate Honey, just have a drink, it will calm your

nerves Marijuana use Self medication can lead to abuse 35 Mental Health/Co-occurring Treated separate until 1990s Sequential treatment was the norm No longer a hard line between diagnoses or treatment

Integrated Approach now used No single option for every combination Must personalize 36 Mental Health/Co-occurring Begin treatment mental health disorder at the same time as substance abuse You dont know which came first

Combination therapy Medications Behavior Modification Coping Mechanisms Modification of traditional techniques 37 Mental Health/Co-occurring Early treatment is key Integrated approach is necessary

Recovery occurs over months to years Long term, community based approach is needed for success 38 Opioid Forum September 15, 2017 Pregnancy & Newborns

Susan Peck, D.O. 40 Pregnancy & Newborns Opiate use in pregnancy increased 5 times in the last decade Increase of NAS 5 times from 1.2 to 5.8 /1000 hospital births Screening of pregnant women Medically assisted treatment methadone and

buprenorphine Medically assisted withdrawal during pregnancy 41 Pregnancy & Newborns Prenatal care Peripartum pain management Postpartum care Post operative pain management for discharge

42 Pregnancy & Newborns NAS needs 3-5 days for evaluation - can be from MAT, narcotics or other psychoactive drugs Screening needs to be universal Keep mother and baby dyad together Encourage breast feeding

43 Pregnancy & Newborns Future needs for opioid use in pregnancy: Obstetric research with optimal screening, treatment and care and postpartum care and medically supervised withdrawal in pregnancy Neonatal focus: Better scoring system that helps determine pharmacologic management Optimal nonpharm and pharm approaches to management

Information on long term effects of MAT Understand genetics and train multidisciplinary providers 44 Emergency Medicine Greg S. Swartzentruber, M.D. Emergency Medicine: Perspective

Emergency Medicine: The Problem Many focus EDs role as a pipeline for opioid prescriptions EDs account for only 5% of opioids ED physicians are low-risk providers Contribute very little to opioids prescribed to patients with OUD

Emergency Medicine: The Opportunity Emergency Medicine: The Warm Hand-Off Evaluation by substance abuse specialist Initiation of treatment Direct referral to treatment

Emergency Medicine: The Solution The ED: The Solution? Screening, brief intervention, referral to treatment (SBIRT) Screening, treatment initiation, and referral (STIR) Emergency Medicine

The ED: The Solution? Hospitals Frank E. Mozdy, M.D. 52 Hospitals

Complex medical care, psychosocial needs, handoffs to outpatient followup Increasing burden of opioid related care Policies 34% ICU Admits Withdrawal treatment & MAT therapy 58% Costs Addressing violent encounters Harm reduction education for users

53 Hospitals: Withdrawal vs Treatment Acute withdrawal Opioid substitution Methadone or buprenorphine rapidly tapered Supportive medications

Blocking withdrawal symptoms with clonidine Treat individual symptoms Diarrhea, nausea, muscle spasms, insomnia, anxiety, etc. 54 Hospitals: Withdrawal vs Treatment Medication Assisted Treatment No special waver to start MAT in hospital

Methadone, buprenorphine Opioid blocker (Vivitrol) Must only be done with proper link to outpatient MAT program and counseling 55 Hospitals: Harm Reduction

Safe injection education Opioid overdose education Naloxone prescription on discharge Syringe exchange programs 56 Hospitals: Other Considerations

Treating acute pain for MAT patients or on other opioids Polysubstance use Risky prescribing patterns in community Availability of addiction specialists Rural & resource-limited areas New Joint Commission pain standards 57 Hospitals:

New Joint Commission Pain Standards Facilitate non-pharmacologic pain treatment Facilitate access to PDMP for clinicians Prioritize pain assessment & management Minimize pain treatment risks Monitor performance with data collection/analysis Actively involve clinical leaders to improve care & services 58

Pharmacists PJ Ortmann, RPh 59 Pharmacists Communication

Collaboration Manage Expectations Prescribers Patients Pharmacists Family 60

Pharmacists: Beyond Dispensing Pharmacists must balance Challenges: Clinical

Professional Legal Financial (Insurance Limitations / Cash) Criminal 61 Pharmacists: Prescription Management

PDMP Controlled Substances Agreements (CSA) Total Medication review and oversight Communication Among Prescribers / Patients / Pharmacists

LCPA Pharmacy Hotline 62 Pharmacists: Naloxone Narcan (naloxone) nasal spray Access Pa Standing order

(e.g. Allowable on Request) Availability Most Pharmacies (Nasal Spray) Cost - $150 or Insurance copay Dispensed with instructions/demonstration Reported to Physician 63 Pharmacists:

Disposal / Take Back Medication Disposal / Collection Police Collections boxes (County Website) Pharmacy take-back (some) Appropriate Trash disposal (LASA, LCSWM) 64 Panel Discussion

Q&A Carrie L. DeLone, M.D. 65 Closing Remarks Michael J. Consuelos, M.D. Senior Vice President, Clinical Integration

66 Your steps Visit the website www.opioidaware.org and share it with others Get involved in your Countys Anti-Heroin or Drug Task Force Promote message of safe use, storage and disposal of medications Our next steps We will continue to work together to advance best practice guidelines to combat the opioid epidemic.

67 Thank You! 68

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