Opioid Efforts in Los Angeles County – Updates

1. Opioid Efforts in Los Angeles County – Updates Gary Tsai, MD, FASAM, FAPA gtsai@ph.lacounty.gov Medical Director & Science Officer Substance Abuse Prevention and Control County of Los Angeles Department of Public Health

2. Outline • The Opioid Epidemic in Los Angeles County • Snapshot of Opioid-Related Data in LAC – Updates • Safe Med LA & Other Opioid-Related Initiatives • Progress • Emerging Priorities • Future Opioid-Related Considerations

3. Key Factors in the Evolution of the Opioid Epidemic • “Quick fix” culture  Pain pills are quicker and less work than alternative therapies • Misinformation from pharmaceutical companies pushed notion that opioids were not addictive unless given to people with dependencies already • Lobbying for pain as the “5th vital sign” Institutionalized pain treatment during every patient encounter • Under-resourced SUD systems • Under-utilization of Medications for Addiction Treatment & Naloxone • Lack of addiction specialists • Increasing potency of opioids (fentanyl, carfentanil)  Counterfeit pills have exacerbated risk Overuse of opioids Lack of Treatment Options Increased overdose risks

4. Snapshot of Opioid-Related Data in LAC– Updates 53

5. Emergency Department Visits – Primary Prescription Opioid Overdose Recent Trend

6. Hospitalizations – Primary Prescription Opioid Overdose Recent Trend

7. Drug Overdose Deaths, US and LAC Los Angeles County United States • On average, 174 Americans died every day from a drug overdose in 2016 • On average, more than 2 people died every day from a drug overdose in 2016 Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2016 on CDC WONDER Online Database

8. Opioid-Related Death Rates by Race/Ethnicity and Gender in LAC Rates per 100,000 population. API: Asian or Pacific Islander. Source: Multiple cause of death data. California Department of Public Health.

9. Emergency Department Visits –Heroin Overdose-Related Recent Trend

10. Hospitalizations –Heroin Overdose-Related Recent Trend

11. Heroin-Related Deaths ≈ Stable Trend

12. Opioid Prescribing Trending Source: California Department of Public Health; California Opioid Overdose Surveillance Dashboard

13. “Doctor Shoppers” Trending

14. CURES – California’s Prescription Drug Monitoring Program (PDMP) Trending

15. Treatment –Buprenorphine Prescribing *Buprenorphine is a Medication for Addiction Treatment (MAT) Trending Source: California Department of Public Health; California Opioid Overdose Surveillance Dashboard

16. Treatment Admissions in Specialty SUD System (SAPC) –Primary Prescription Opioid Related Trending

17. Treatment Admissions in Specialty SUD System (SAPC) –Primary Heroin Related Slight Trend

18. Safe Drug Disposal Trending

19. Opioid-Related Efforts Underlying the Data 18

20. Opioid-Related Efforts Across LA County • Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver – Medicaid waiver to transition the specialty substance use disorder (SUD) treatment system to a managed care model, including treatment for opioid use disorders • Safe Med LA • California Health Care Foundation (CHCF) Opioid Safety Network Grant (~$60K, completed) • CDPH Naloxone Grant (10,800 doses of naloxone, in process) • Center for Health Leadership and Practice Accelerator Program (2 AmeriCorps volunteers and leadership development, in process) 19

21. Opioid-Related Efforts Across LA County (cont’d) • California Hub and Spoke Grant • LA received ~$8M, but this Hub and Spoke grant was operationalized through Opioid Treatment Program (OTP) providers directly, as opposed to going through the County. DPH and DMH are coordinating with the OTP leads, but are not leading this effort. • Two OTP providers in LAC (Matrix Institute and Tarzana Treatment Centers) are serving as hubs to provide resources and expertise to spoke community-based providers (FQCHs, primary care clinics) to support the availability of medications for opioid use disorder treatment. • HElp for Addiction Recovery and Treatment (HEART) Collaborative – Board motion to establish a workgroup to focus on opioid-related efforts. • Focuses include branding, DPH oioid media campaign, Antelope Valley pilot to expand access to afterhours care, and coordinate data across agencies. • Includes the CEO’s Office, LAC Health Agency, LA Sheriff’s Dept(LASD), LAC Fire Dept (LACoFD), MedicalExaminer-Coroner’s Office, Office of Diversion and Reentry (ODR), and other pertinent groups. 20

22. Opioid-Related Efforts Across LA County (cont’d) • CHCF Grant for DHS • CHCF awarded three DHS sites (LAC+USC, Harbor-UCLA, and MLK Outpatient Center) a $50K grant from 2016-2018 for technical assistance to support prescribing buprenorphine to county patients with opioid use disorders. • LA Community Collaborative (LAC3) between TLI Foundation, DPH and DMH • DPH, DMH, and the Think. Lead. Innovate. (TLI) Foundation are exploring a prevention-focused initiative that proposes to raise $5M to fund cross-sector collaboratives to address the upstream drivers of opioid problems and diseases of despair in the County. County and community partners would serve as the primary participants, led by the TLI Foundation and County leadership. 21

23. Opioid-Related Efforts Across LA County (cont’d) • National Institute on Drug Abuse (NIDA) R34 Grant, “Developing Capacity for Opioid Use Disorder Treatment in Mental Health” • Grant submission in process in partnership between DMH and RAND Corporation. • $800K grant proposes to fund RAND Corporation to evaluate the organizational readiness and client perceptions for integrating medications for opioid use disorder into standard treatment for DMH clients, and RAND Corporation would develop and publish a toolkit that DMH clinics can use to increase the number of individuals served by DMH receiving treatment for opioid use disorder. 22

24. Safe Med LA • Safe Med LA is a broad, cross-sector coalition that is taking a coordinated and multi-pronged approach to comprehensively address prescription drug abuse in Los Angeles County  www.SafeMedLA.org 23

25. PROGRESS – Safe Prescribing • Implemented safe prescribing guidelines at all 78 emergency departments and 80 urgent care clinics (UCC) throughout LAC. • In process of implementing safe prescribing guidelines at remaining 160 UCCs, as well as additional primary care clinics across the County. • Educated 5000 dentists across LAC on safe prescribing. • Convened six Medical Practice Round Table meetings including all major health plans in LA County to establish and adopt standardized safe prescribing benchmarks. • Outcomes • 11% decrease in the opioid prescribing rate during the first two years of Safe Med LA’s establishment, from 2015 – 2017 (data from CDPH). • “Doctor shoppers” (defined as patients who used > 5 prescribers and 5 pharmacies over 6 months) decreased 50% from 2015 – 2016 (data from CURES). 24

26. PROGRESS –Medications for Addiction Treatment (MAT) • Trained > 240 new buprenorphine prescribers in LAC. • Leading two MAT learning collaboratives, one focused on supporting MAT in primary care and another on supporting MAT in the specialty SUD system. • Supported 8 community health centers (FQHC’s) in implementation of MAT programs, with additional FQHC’s coming online in the future. • Supported over 10 community substance use disorder (SUD) treatment provider agencies in implementation of MAT programs, with additional agencies coming online in the future. • Launched web-based MAT Resource Library to support expansion of MAT programs  http://www.uclaisap.org/mat/index.html • Successfully advocated for the expanded access of long-acting naltrexone (aka: Vivitrol) for all Med-Cal beneficiaries as a pharmacy benefit. • Outcomes • 8% increase in the annual buprenorphine prescribing rate in LAC from 2015 – 2017 (data from CDPH). 25

27. PROGRESS –Naloxone • Trained > 235 pharmacists on the State-required training to enable them to furnish naloxone without a physician prescription. • As a component of the Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver implemented by LA County’s SAPC, added over 50 additional sites across the County where naloxone is accessible to the community through Opioid Treatment Programs (OTP) via Drug Medi-Cal. • Supported LASD with the launch of its naloxone program, which is one of the largest in the country, with 11 lives saved since implementation of LASD’s naloxone program in 2017. • Collaborated with the LA County Fire Department and LASD to obtain their naloxone administration field data to take a data-driven approach to inform the County’s naloxone intervention efforts. • Outcomes • Distributed > 21,000 doses of naloxone to community-based organizations and law enforcement in LAC through CHCF grant and CDPH naloxone grant. 26

28. PROGRESS –Other Opioid-Related Efforts • Surveyed 9,500 LAC residents on prescription drug abuse, focusing on the following domains: risk perception, perception of access/availability, attitude toward use, patterns of use, motivation for use, and consequences of use. • This data was presented at the Los Angeles County Science Summit and used to take a data-driven approach to inform the work of the Safe Med LA Action Teams, in particular the Community Education Action Team. • Safe Med LA’s Community Education Action Team engaged over 40 substance use prevention providers to develop regional strategies to provide community education and engagement on the opioid epidemic and prescription drug abuse that is tailored to their unique communities. • Safe Med LA’s Safe Drug Disposal Action Team worked with the Community Education Action Team to expand the number of annual safe drug disposal take-back events throughout LA County. Sheriff stations and DEA Offices now organize drug take-back events on a monthly basis, in addition to the national drug take-back days. • Distributed 5,300 fentanyl test strips to support fentanyl-related education and the distribution in the community, particularly in the high-risk populations served by the LGBT Center and their partner agency, the Community Health Project of Los Angeles (CHPLA). 27

29. Emerging Priorities • Fentanyl • Health alert about fentanyl overdoses related to illicit drug use released 5/24/18. • Increase in fentanyl-related deaths, largely due to illegally manufactured illicit drugs laced with fentanyl. • Tracking fentanyl-related overdoses via surveillance and collaboration with Medical Examiner-Coroner’s Office. • LA Joint Regional Intelligence Center implementing ODMAP real-time surveillance system for drug overdoses, including fentanyl. • Sustainable funding for law enforcement naloxone program • Start-up doses of naloxone have been provided to LASD through various grants, but sustainable funding will be needed to sustain naloxone programs by law enforcement entities. • Opioid prevention media campaign • DPH planning to implement opioid prevention media campaign in mid-2019. 28

30. Future Opioid-Related Considerations • Opioids are deservedly attracting significant attention, focus, and resources, and will likely continue to do so until the opioid epidemic is better controlled at a national level. • Adding more resources to a problem is generally helpful, assuming there is strategic focus and coordination of efforts to maximally utilize those resources. • DPH has thus far served as the lead for opioid across the County.As more initiatives focused on opioids are implemented moving forward, including those implemented through other health departments and County agencies, ensuring coordination of efforts across the Health Agency and County will be a priority. 29

31. Q&A / Discussion “The opposite of addiction is not sobriety; the opposite of addiction is social connection.” - Johann Hari