Opiate Use and Misuse in Oregon – Efforts from a Healthcare for the Homeless Clinic

1. Opiate Use and Misuse in Oregon – Efforts from a Healthcare for the Homeless Clinic Rachel Solotaroff, MD, MCR Medical Director, Central City Concern May 2, 2013

2. Objectives • Brief introduction of the opiate crisis in our community and in our clinic • Our process as a clinic and a community in understanding and addressing this crisis • Lessons learned

3. Disclosures • No financial relationships to disclose • I am a clinician and colleague; not an expert • I am an incrementalist; not a trailblazer

4. background

5. Central City Concern • CCC’s Mission: • “To provide comprehensive solutions to ending homelessness and achieving self-sufficiency” • Continuum of integrated services: • Affordable housing • Addictions treatment • Mental health services • Recovery support • Employment services • Primary care

6. Old Town Clinic • Integrated into CCC in 2001 • Healthcare for the Homeless Clinic • 3500 patients; 15,000 PCP visits • 35 percent uninsured • 99 percent at 100% FPL or below • 60-80 percent homeless • High prevalence of addiction & mental health disorders • Internal medicine; integrated BH, Pharmacy & OT • Strong complementary medicine department (ND, Acup) • Social medicine curriculum with OHSU Dept. of Medicine • Other robust academic partnerships (Pharm, PMHNP, OT)

7. Opiate use and abuse in Oregon – Where we stood in 2008

8. Deaths due to Drug Poisoning in Oregon Oregon Health Authority, Office of Disease Prevention and Epidemiology

9. Hospitalizations Oregon Health Authority, Office of Disease Prevention and Epidemiology

10. Who’s At Risk? Oregon Health Authority, Office of Disease Prevention and Epidemiology

11. The Role of Methadone Supportive Housing

12. Methadone: Grams Sold and Death Rate.

13. Factors Among Methadone Decedents • 41% prescribed methadone; 30% no Rx • Prescriptions: 43% pain; 26% methadone maintenance • In 77%, abuse contributed to death • 75% history of substance abuse • 21% history of substance abuse treatment • 52% history of mental illness • Sample N=56 Oregon Health Authority, Office of Disease Prevention and Epidemiology

14. Pain Medication Misuse • 2013: Oregon is THE highest state for nonmedical use of prescription pain relievers: • 6.4% of all persons >12 years • 7.4% of persons 12-17 years • 15% of persons 18-25 years • 2008: Oregon is 5th highest state for nonmedical use of prescription painkillers* • 6.6% of persons >12 years • 8.2% of persons 12-17 years • 17.9% of persons 18-25 years – highest in any US state SAMHSA- 2008, 2013 National Survey on Drug Use and Health, state level data

15. Summary • 53% of drug overdoses in Oregon associated with prescription opioids • Overall: 540% increase in since 1999 • Methadone: 1,500% increase in deaths since 1999 • 33% of all drug-related deaths (licit and illicit) associated with methadone Oregon Health Authority, Office of Disease Prevention and Epidemiology

16. Addressing the epidemic

17. Back at Home… • Providers: • - Aware of lack of evidence and risks of opiates • - Trying to grapple with patient expectation that “ a pill will make me pain free” • - Lack of patient engagement with alternative modalities for pain management • - Clinic sessions clogged with patients needing refills • - Calls from the Medical Examiner when a death occurred • Staff • - Struggling with phone calls and walkins for refills • - Managing behavioral issues when refills not granted as expected

18. Step 1: Establish Uniform Oversight and Prescribing Guidelines • Controlled Substances Review Committee: • Reviews all episodes of serious misuse or misconduct • Reviews all requested new starts on chronic opiate therapy • Provides guidance for complex pain management cases • Early prescribing guidelines: • When to refer to CSRC • Prescribing to patient on methadone maintenance, in A&D treatment • Process for new opiate starts • Other contra-indicated substances Chelminski et al. BMC Health Services Research 2005, 5:3 

19. Step 2: Integration of non-pharmacologic pain management and addiction • Occupational Therapy/Group Visits • Naturopathic Medicine/Acupuncture • Education series for providers: • Trigger Point Injections • Musculoskeletal Exam • Physiatry 101 • Integrated Chronic Pain and Addictions Program – • “Hot Sauce”: • Led by CADC • 12-week curriculum • Focus on triggers, relapse prevention, alternative pain management

20. Patient, Staff and Provider Response • Providers: • Relieved at no longer having to “go at it alone”; “makes being strict less personal”; “enables discussions around public health concerns” • Appreciative that we were no longer a “juice bar”; still feel patients need to embrace acceptance of their responsibility in pain management • Unclear of “net benefit”of Hot Sauce program • Staff: • Perceived decreased burden of phone calls and walk-ins • Patients: • Some felt groups were supportive and helpful; others felt they were a waste of time • Empathy with providers over having to “answer to some committee”

21. Step 3: Community-Wide Approach • Multnomah County Health Department Guidelines 2011: • Instituted dosage ceiling limit on chronic opiate therapy • Established absolute contra-indications to COT • Established conditions for which chronic opiates could not be prescribed • Community Response: Get on the train, or get run over by the train • Oregon Prescription Drug Monitoring Program, 2011 Death of Sam Barlow High School senior last December ruled an overdose 13-year-old Medford boy may have died from prescription drug overdose, police say

22. Our Current Controlled Substances Policy ABSOLUTE CONTRAINDICATIONS: • Any history of diversion • No functional improvement • No complete workup for pain diagnosis • Active substance abuse • No non-pharmacological modalities tried, or unwillingness to try them • Greater than 120mg daily of morphine equivalents (40mg methadone) • Use of marijuana (licit or illicit)

23. Our Current Controlled Substances Policy RELATIVE CONTRAINDICATIONS (moving toward absolute*): • High opiate risk score • No BH screening or undertreated BH condition • History of suicide attempt • Currently on methadone maintenance • History of misuse/overuse • Concurrent use of benzodiazepines *While we have made judicious exceptions in these areas, evidence and clinical experience are showing poor results

24. Chronic Pain Recovery Pyramid Level Three Hot Sauce Weekly Acupuncture RENEW Monthly Group Visits with OT/PCP Behavioral Health Assessment or Impact Monthly “Activity Groups” Level One Primary Care Only q 2-3 mo visits Strengthening Our Systems and Supports Graduation Criteria: -- Level 3: completion of Hot Sauce -- Level 2: Progress toward goals Engaged in Behavioral health (if nec) Reduction in opiate dosage • High addiction risk: • Brief relapse • Early Recovery • Minimal support Risk Management -- UDS – q 3 months -- pill count – q 6 months -- ADR’s – q 3 months -- PDMP: annually Level Two • Low addiction risk BUT: • Low self-management • Low social supports • Low function/activity • Low addiction risk: • Good self-management • Good support • Good function/activity

25. Chronic Pain Recovery Program Road Map • CSRC Reviews Data and recommends: • -- No Controlled Substances + Care Plan Recs -- OR -- • -- Controlled Substances + Level of Care + Care Plan Recs: • Hot Sauce (Level 3) • RENEW Provider Groups (Level 2) • Primary Care Only (Level 1) • Other recs such as BH, medication regiment, monitoring guidelines, etc. • CP Identified at Intake: • -- ROI’s • -- CP acknowledgemt • -- BH Screen: • ORT • PHQ • GAD-7 • PTSD Screen OT Assess Behavioral Health 4 weeks Income & Employment Volunteering, Training, Jobs PCP Appt #1 PCP Appt #2 H&P, Record Review, UDS, OPDMP query If + BH Screen

27. Lessons learned

28. Lessons Learned • Absolute necessity and benefit of guidelines and review committee to which we all adhere • “Cognitive dissonance” between population level data and the patient sitting in front of you • While it’s great to have so many wellness resources, patient still needs to be engaged and receptive • Addictions/Chronic Pain program such as “Hot Sauce” is innovative, but integration of suboxone has been the game-changer • Need better focus on/understanding of intersection of trauma, addictions and chronic pain

29. Thank you!