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Louisiana Opioid Epidemic Impact and Response AHFSA 2019 Annual Conference August 6, 2019

Louisiana Opioid Epidemic Impact and Response AHFSA 2019 Annual Conference August 6, 2019. Louisiana Department of Health James Hussey, M.D. Medical Director Louisiana Office of Behavioral Health. Presentation Overview. What are Opioids? Treatments for Opioid Use Disorders

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Louisiana Opioid Epidemic Impact and Response AHFSA 2019 Annual Conference August 6, 2019

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  1. Louisiana Opioid EpidemicImpact and ResponseAHFSA 2019 Annual ConferenceAugust 6, 2019 Louisiana Department of Health James Hussey, M.D. Medical Director Louisiana Office of Behavioral Health

  2. Presentation Overview • What are Opioids? • Treatments for Opioid Use Disorders • Opioid Crisis: National Perspective • Opioid Crisis: Louisiana Perspective • Federal Strategies Overview • Louisiana Strategy Overview • Louisiana Responses to Opioid Crisis

  3. What are opioids?

  4. Opioids are psychoactive substances derived from the opium poppy or their synthetic analogs, which are largely used for pain management (or large animal anesthetic in case of carfentanil) Prescription Pain Medications: Vicodin Percocet Hydrocodone Morphine Fentanyl Etc. Illicit opioids: Heroin Fentanyl analogs Non-medical use of prescription drugs

  5. Opioid Epidemic and Pain Management • More than 30% of Americans have some form of acute or chronic pain. • In 2014 alone, U.S. retail pharmacies dispensed 245 million prescriptions for opioid pain relievers. Of these prescriptions, 65% were for short-term therapy (<3 weeks), but 3 to 4% of the adult population (9.6 million to 11.5 million persons) were prescribed longer-term opioid therapy. • If opioids are used in sufficient quantity over a prolonged period, users will become both physically and psychologically dependent. • With the advent of prescription monitoring programs, providers can more readily identify individuals who exhibit drug seeking behavior. Such individuals may turn to other substitutes including heroin, synthetic opioids, or purchase of fake pills form the black web that may contain deadly doses of fentanyl/carfentanyl.

  6. Fentanyl and Carfentanil • Fentanyl, a drug that is 30 times stronger than heroin and claimed the lives of more than 20,000 Americans last year, is showing up in both Canada and the United States. • Carfentanil or carfentanyl is an analogof the synthetic opioid analgesic fentanyl. A unit of carfentanil is 100 times as potent as the same amount of fentanyl, 5,000 times as potent as a unit of heroin and 10,000 times as potent as a unit of morphine.

  7. Fake Pills and Contaminated Cocaine Drug dealers are making FAKE pills, and are mixing large animal tranquilizers (fentanyl, carfentanil) into pills like Xanax, Percocet, Norco/Hydrocodone, Oxycodone, and even into other drugs like cocaine. So, nobody can be sure what is actually in these substances. Any one dose could be lethal! Fake Xanax Fake Hydrocodone Fake Percocet Can you find the one grain of carfentanil in any of these? Real Cocaine

  8. This may get worse before it gets better… Why are se seeing such a dramatic increase in opioid-related deaths? • A Multifaceted problem: • Provider clinical practices • Insufficient oversight • Inappropriate prescribing • Insurance and pharmacy benefits policies (increased supply) • Misconceptions about opioid tolerance, dependence addiction, and treatment • Over-reliance on opioid medications for chronic pain • Lack of understanding of dangers involved with illicit drug use, fake pills, etc. • Although ALL opioids can produce tolerance, dependence, and possible addiction, if taken in sufficient doses for long enough, some are more addictive and lethal than others. • Doses above 50 MME/day doubles the risk for OVERDOSE. (e.g., 50 mg of hydrocodone, 33mg of oxycodone, etc .) –CDC • Little evidence to support opioid effectiveness beyond 2-6 weeks. • Caution if prescribed more than 3-7 days.

  9. Treatments for Opioid Use Disorder

  10. Medication-Assisted Treatment (MAT) Medication-assisted treatment, including opioid treatment programs, combines behavioral therapy and medication to treat substance use disorders R As a part of grant awards, LDH Office of Behavioral Health will be able to expand and enhance capacity for MAT, wraparound services, and recovery support services for individuals with opioid use disorders x +

  11. Medication-Assisted Treatment (MAT) There are three medications commonly used to treat opioid addiction: R • Methadone– clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it; daily liquid dispensed only in specialty regulated clinics (agonist) • Naltrexone– office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection (antagonist) • Buprenorphine– office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk; daily dissolving tablet, cheek film, or 6-month implant under the skin (partial agonist, with less euphoria, less respiratory depression, and less dependence ) x

  12. MAT Misconception • Medication-assisted therapies are just substitutes for heroin or abused opioids. Although these are opioid agonists, their slower brain pharmacokinetics, along with their more stable concentrations help to stabilize physiologic processes that are disrupted by intermittent abuse of opioids. The use of these drugs also protects against risks associated with opioid abuse while facilitating recovery.

  13. National Perspective • An opioid overdose death occurs approximately every 15 minutes. • 115 Americans die every day from an opioid overdose; more than 42,000 deaths in 2016 alone. • Opioid death rates were five times higher in 2016 than in 1999 and continue to rise. • Of those addicted in the United States, 2.1 million are addicted to prescription drugs, and 517,000 are addicted to heroin.* • *SAMHSA, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: SAMHSA, 2013

  14. Nationwide: The sharpest increase in overdose deaths in 2016 occurred among those related to fentanyl analogs (synthetic opioids) resulting in over 20,000 deaths.

  15. Deaths by specific opioid drugs used –Louisiana, 2014-2018 Data indicate a recent and rapid shift from prescription opioids to illegal opioids, and this change in composition of deaths and hospitalizations must be taken into account when implementing prevention and treatment activities.

  16. Louisiana PerspectiveOpioid-involved deaths occurring in Louisiana, 2012-2018 Between 2012 and 2018, the number of overdose deaths involving opioids almost tripled in Louisiana. In 2018, more than 450 Louisianans died of opioid-involved overdoses, a 13.5% increase from 20172, the highest number of opioid-related deaths on record in Louisiana.

  17. Impact on Louisiana (Medicaid) • 2018 Louisiana Opioid-related deaths: more than 450 opioid-involved deaths. • Number of opioid (pain) prescriptions filled in State Fiscal Year 2018: 728,417 for 263,557 unduplicatedrecipients; Medicaid paid amount: $9,226,856.19. • Treatment (buprenorphine, naltrexone, etc. –excluding methadone) • Prescriptions filled in SFY 2018: 79,918; Related Medicaid cost: $25,686,680.19. • Number of days spent in the Emergency Department in State Fiscal Year 2018 related to opioids: 7,886; Related Medicaid costs: $1,858,797.35. • Number of Inpatient Hospital Admits in State Fiscal Year 2018 related to opioids: 9,834; Related Medicaid costs: $39,755,833.49. • Number of Naloxone prescriptions filled in State Fiscal Year 2018: 1,426; Related Medicaid costs: $229,527.14 • Number of unduplicated Medicaid recipients who received a specialized substance use disorder residential treatment: 6,286; Medicaid cost: $34,153,438.78. • Number of unduplicated Medicaid recipients who received a specialized substance use disorder outpatient treatment: 4,622; Medicaid cost: $6,212,219.71. • Total from above: >$117,123,350

  18. Impact on Louisiana • Of approximately 33,000 offenders in Department of Corrections’ custody currently, 1,039 have an active offense known to be opioid-related. Over 47% are between ages 30 to 39 years old. • According to 2017 Youth Risk Behavior Survey, 19.3% of high school students took prescription pain medicationswithout doctor’s approval or not as prescribed. • According to 2017 Youth Risk Behavior Survey, 9.6% of high school students claimed to have used heroin one or more times in their life. • During Federal Fiscal Year 2017, 1,715 Newborns were identified and validated as Drug/Alcohol Affected Newborns, which is inclusive of those affected by the unlawful use of opioids.

  19. Opioid Strategies National and Louisiana

  20. The Federal Health and Human Services (HHS) Opioid Strategy

  21. Louisiana Goals for Opioid Crisis Better Data Prevent Opioid Addiction Intervention: Enhance Intervention and Rescue Activities to Prevent Deaths Treatment Services: Increase quality of and access to treatment of Opioid Use Disorders Recovery: Effective Recovery Support Services

  22. Opioid-related laws passed in 2017 PMP Enhancement PMP Applicability Advisory Council Seven Day Supply Law strengthens our Prescription Monitoring Program, including mandated registration for any prescriber, and mandated queries before opioids are prescribed and every 90 days during treatment. Continuing education for controlled substance prescribing Law broadens the Prescription Monitoring Program access to include counselors, parole officers, medical examiners, coroners Law limits first-time prescriptions of opioids for acute pain to a seven day supply, with exceptions when medically appropriate Law creates a 13-member advisory council on heroin and opioid prevention and education (HOPE)

  23. 2019 Louisiana Legislative Session • HB 250: Requires licensed residential SUD treatment facilities to provide onsite access to antagonist (naloxone) and agonist (MAT) treatment. • HCR 71: Requests LDH to issue regulations to allow the establishment of new opioid treatment programs and methadone dosing sites. • HCR 118: Urges the OBH to ensure access to substance use disorder treatment in central La. pursuant to the impending closure of four residential treatment facilities in that area. • HR 257: Requests LDH to study the benefits and costs of eliminating prior authorization for MAT. • HR 291: Requests LDH study changes needed to increase access to outpatient SUD treatment, including MAT. • SCR 25: Requests the LDH to study the use of scrambler therapy as an opioid alternative for the treatment of pain in consultation with the Louisiana Department of Insurance and the Louisiana Association of Health Plans. • SCR 31: Establishes LDH as the lead agency for the annual Interagency Heroin and Opioid Coordination Plan. • SCR 84: Request LDH to take steps in approving peer support services under Medicaid.

  24. Louisiana Surveillance(Better Data) Office of Public Health, Office of Behavior Health, and Louisiana Medicaid

  25. Louisiana Opioid Surveillance Initiative Office of Public Health Data-Driven Prevention Initiative • Accesses existing LDH databases and partners with external organization to collect and analyze health data related to opioid use disorder. • Results disseminated through facts sheets, publications, training and educational materials, and the online data and surveillance system. • Collaborates with the Prescription Monitoring Board to disseminate data on the opioid prescription patterns in the state.

  26. Challenges in Classification of “Opioid Involved Deaths” • Cause of death secondary to drug toxicity: Opioids can be in a person’s system and cause organ failure or brain injury. • Mixed drug intoxication: Opioids are often mixed with other drugs, such as cocaine, methamphetamines, benzodiazepines, etc. • Drug classification: “Opioid” encompass a broad array of drugs, including heroin, fentanyl, and various prescription medications which are hard to differentiate from one another. • Coroner discretion in determining the cause of death as opioid related.

  27. Louisiana’s Response & Approach to the Opioid Epidemic • Governor’s Advisory Council on Heroin and Opioid Prevention and Education (H.O.P.E. Council) – Act 88 of the 2017 Regular Session • Data and Surveillance Committee • Coordination Plan Committee • LDH Steering Committee • Office of Public Health – Surveillance • Office of Behavioral Health – Prevention and Treatment • Medicaid – Policy • Bureau of Media and Communications, LDH Leadership • Local/Regional Response • Local Governing Entities (Florida Parishes Human Services Authority) and Local Partners

  28. Opioid-Related Grants The Louisiana Department of Health, Office of Behavioral Health and Office of Public Health are the recipients and overseers of over $50 million in grants for prevention, expansion of Medication Assisted Treatment, monitoring of opioid prescriptions, prescription drug overdoses, and the development and coordination of the State Opioid Response.

  29. Louisiana State Targeted Response (STR)Federal Grants to the Office of Behavioral Health • Prevention Services • Education on preventing and managing opioid overdoses • Access to overdose reversal drugs (naloxone) • Encourage the public to call 9-1-1 • Encourage prescribers to check prescriptions using the state Prescription Monitoring Program • Intervention/Rescue Services: • 3,161 of 4,000 Narcan kits distributed to LGE’s based on needs assessment. • Treatment Services • Methadone treatment to uninsured and underinsured in local OBH offices (535 new & 181 year 1 clients) • Expand counseling and treatment services at the local level • Promote psychosocial counseling and behavioral therapy • Increase by 1,670 the number of individual with OUD being treated with EBP’s (835/yr for two years) • Recovery Services • Provide assistance to opioid use disorder (OUD) patients with housing, benefits, vocational and educational opportunities • Assist clients moving successfully through the stages of treatment and recovery. • Ensure each client is connected to all available services • Increase recovery supports for 600 OUD clients, (300/yr x 2 yrs) • Department of Corrections Partnership • Make medication therapy available prior to release • Offer monthly medication and aftercare services to ensure continuity of care

  30. Louisiana State Opioid Response (LaSOR) Grant • Who is served? • Under/uninsured • Criminal Justice population • State-recognized tribes • Pregnant women and women with infants experiencing neonatal withdrawal symptoms • School-aged children/communities (prevention) • What are the Goals? • Increased access to Medication Assisted Treatment (MAT) • Increased access to recovery and support services • Increased outreach to community programs • Identify and address needs of state-recognized tribes • Increase public and professional awareness, education for prevention and treatment for OUD’s.

  31. LaSOR Grant, continued… • What are anticipated outcomes? • Enhance prevention, treatment & recovery services by expanding education, outreach & MAT treatment availability statewide • Build capacity of Opioid Treatment Programs (OTPs) to serve an additional 30 persons/year (600/2yrs) • Establish and support Office Based Opioid Treatment (OBOT/bupenorphine) providers, allowing increased access to care, expansion of community crisis/outreach mobile teams • Increase recovery supports. • Ultimate goal to reduce overdose deaths. • What is the model? Hub & Spoke • (10) Opioid Treatment Programs (OTPs) = Hubs • (50) Office Based Opioid Treatment (OBOT) providers = Spokes (e.g., community prescribers, LGE’s, FQHC’s w/in 25 miles of Hubs. Each spoke with 20 new clients = 1,000 clients/year or 2,000 over 2 years) • Spoke Care Teams (RN and LMHP) –recruited and trained by LSU-HSC, New Orleans • ECHO Model (training, consultation and academic detailing through Tulane

  32. Louisiana Hub & Spoke Model

  33. LaSOR Status Overview • Contracted with 10 Opioid Treatment Programs (OTP) to become LaSOR HUBS • 154 Individuals being served by HUBS as of 06/01/2019 • Contracted with Louisiana State University / Health Sciences Center (LSU/HSC) to establish 50 OBOT Providers as SPOKES • Collaborated with OPH to pilot SBIRT Project for pregnant women under NAS Initiative • Contract with Oxford House approved 05/14/2019 & Naloxone trainings at 118 Oxford Houses • Contract with Louisiana State University / Social Research Evaluation Center to conduct a tribal needs assessment. • Established Relationship with Governor’s Office of Indian Affairs & Contacted State Tribal Councils • Conducted Adolescent Listening Sessions at Bayou Pride Summer Camp for Youth • Executed MOUs with each of the 10 Local Governing Entities to form Crisis Mobile Teams: • 12 Overdoses reversed • 3,460 Narcan Kits Distributed • 500 Disposal Bags Distributed • 8,958 Individuals Reached by Crisis Mobile Team(s)

  34. Naloxone Standing Order • Naloxone is the an opioid antagonist that can reverse the effects of an opioid overdose. • In January 2017, Louisiana issued its first “standing order” for naloxone, allowing for participating pharmacists to dispense naloxone without a formal prescription to lay persons including caregivers, family, and friends of an opioid user. • The order also included direction on how to administer naloxone to someone who has overdosed. • LA Medicaid: Since January, 2017 there have been approximately 480 claims paid for Naloxone, with the majority of these claims paid for the Narcan Nasal Spray at an average cost of $128.00.

  35. Naloxone distribution LDH Bureau of Emergency Medical Services (EMS) is distributing free auto-injector naloxone kits to EMS departments statewide. The Louisiana Attorney General’s Office is offering single draw-down doses of naloxone available to first responders who request them. • The LDH Office of Behavioral Health is distributing free nasal-spray naloxone kits.  As there will be a limited number of kits purchased, priority is given to the following groups:  1) Local Human Services Districts/Authorities based on need; and 2) Opioid Treatment Programs (OTPs) for distribution to their at-risk clients and families. • Note: 10,364 total Narcan kits were distributed through State Targeted Response to Opioid Crisis Grant (STR). Many CVS and Walgreens Pharmacies in Louisiana have Naloxone available without an individual prescription. Image sources: Evzio: https://openi.nlm.nih.gov/imgs/512/216/4470965/PMC4470965_40122_2015_35_Fig2_HTML.png; Vial: http://images.medscape.com/pi/features/drugdirectory/octupdate/HOS12150.jpg; Nasal Spray:https://www.narcan.com/; CVS Logo: https://upload.wikimedia.org/wikipedia/commons/thumb/1/1b/CVS_Pharmacy_Alt_Logo.svg/1280px-CVS_Pharmacy_Alt_Logo.svg.png; Walgreens Logo: https://logos-download.com/wp-content/uploads/2016/02/Logo_Walgreens_W.png

  36. Call to Action • Remember the Louisiana Department of Health’s main message: • ACT on Opioids • Ask your doctor about alternatives to opioids • Call for information and help (referrals for treatment) • Tell your friends and family about dangers of opioids • Do not take ANY pills or medications not prescribed by your doctor and dispensed by a licensed pharmacy (like Walgreens, CVS, RiteAid, WalMart, etc.) Even one grain of carfentanil(the size of a grain of salt or sand) in one of many pills, could be LETHAL. • Do not take opioid pain killers any more than needed. Instead, talk to your doctor about non-opioid alternatives. • Sign a “Non-opioid directive with your doctor.” Do not even risk becoming dependent or addicted. • Get rid of any extra/unused pain pills in your home. • Learn more about overdose reversal medications, like naloxone, available at your pharmacy. • For more, go to LDH website: www.opioidhelpla.org

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