All Hands Approach in the Opioid Epidemic …...2017/10/13 · Female; 43% Male; 57% Female Male N=2437 Unreported(769 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Type(ofInsurance None

An All Hands Approach in the Opioid/Heroin/Fentanyl Epidemic

Michael R. Brumage, MD, MPH, FACPKanawha-‐Charleston Health Department

WVU School of Public Health

An epidemic of epidemics

• Overdoses• Hepatitis B and C (Hepatitis C is the leading infectious killer in the US)• Soft tissue infections, abscesses, and endocarditis and osteomyelitis• Neonatal abstinence syndrome• Children abandoned, neglected, abused, flooding foster care• Homelessness• First responder compassion fatigue/burnout• Needles in public spaces

Harm reduction

• Usually includes syringe services programs• Referral to recovery and treatment services• Hepatitis B, C, and HIV testing• Overdose prevention with naloxone• Immunizations and primary care• Treatment of wounds/abcesses: prevention of endocarditis and osteomyelitis• Connecting with insurance• An attitude of treating with respect and dignity

Community and Academic Partners

• Recovery Point• Prestera• Highland Hospital• Cabin Creek Health System• Fruth Pharmacy• Kanawha Communities that Care• Kanawha Coalition for Community Health Improvement• Many others!

• University of Charleston• Marshall University• West Virginia University• Johns Hopkins University• University of California at San Francisco

Currently (as of 2 weeks ago)

• KCHD Harm Reduction Clinic serves 4,500+ unique patients with an average of 65-‐85 new patients per clinic since December 2, 2015.

• Every Wednesday 10:00 am -‐3:00 pm.• There have been 15,557 visits to the clinic.• 1641 patients have received other services (i.e. Hepatitis testing, HIV testing, STD testing, flu shots, IUD services).

• 248,898 syringes have been returned and 410,717 syringes have been distributed.• 87% return rate, based on patients who have been to the clinic more than once.

• We have trained 1331 people in the use of naloxone and given out as many of the donated Evzio® autoinjectors ($3800 each).

• We know of at least 50 people entering recovery.• We know of at least 220 people’s lives saved by our naloxone program.

Syringe services programs

https://www.cdc.gov/hiv/pdf/risk/cdchiv-‐fs-‐syringe-‐services.pdf

References

1. CDC. HIV and injection drug use: Syringe services programs for HIV prevention [fact sheet]. Accessed May 15, 2017. www.cdc.gov/vitalsigns/pdf/2016-‐12-‐vitalsigns.pdf.

2. Seal KH, Thawley R, Gee L, et al. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. J Urban Health 2005;82(2):303-‐11.

3. Tobin KE, Sherman SG, Beilenson P, Welsh C, Latkin CA. Evaluation of the staying alive programme: Training injection drug users to properly administer naloxone and save lives. Int J Drug Policy 2009;20(2):131-‐6.

4. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Subst Use Misuse 2006;41(6-‐7):777-‐813.

5. Institute of Medicine. Hepatitis and liver cancer: A national strategy for prevention and control of Hepatitis B and C [report]. Accessed June 6, 2017. www.cdc.gov/hepatitis/pdfs/iom-‐hepatitisandlivercancerreport.pdf.

6. Hahn JA, Evans JL, Davidson PJ, Lum PJ, Page K. Hepatitis C virus risk behaviors within the partnerships of young injecting drug users. Addiction 2010;105(7):1254-‐64.

7. Davis CS, Johnston J, De Saxe Zerden L, Clark K, Castillo T, Childs R. Attitudes of North Carolina law enforcement officers toward syringe decriminalization. Drug Alcohol Depend 2014;144:265-‐9.

8. Lorentz J, Hill L, Samimi B. Occupational needle stick injuries in a metropolitan police force. Am J Prev Med 2000;18(2):146-‐50.

9. CDC. FY 2017 president’s budget request [fact sheet]. Accessed June 6, 2017. https://www.cdc.gov/budget/ documents/fy2017/hivaids-‐factsheet.pdf.

10. Heimer R, Khoshnood K, Bigg D, Guydish J, Junge B. Syringe use and reuse: Effects of syringe exchange programs in four cities. J Acquir Immune Defic Syndr 1998;Suppl 18:S37-‐44.

11. Bluthenthal RN, Gogineni A, Longshore D, Stein M. Factors associated with readiness to change drug use among needle-‐exchange users. Drug Alcohol Depend 2001;62(3):225-‐30.

12. Kidorf M, King VL, Peirce J, Kolodner K, Brooner RK. Benefits of concurrent syringe exchange and substance abuse treatment participation. J Subst Abuse Treat 2011;40(3):265-‐71.

13. Strathdee SA, Celentano DD, Shah N, et al. Needle-‐exchange attendance and health care utilization promote entry into detoxification. J Urban Health 1999;76(4):448-‐60.

14. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and

increased entry and retention in drug treatment associated with needle-‐exchange participation in Seattle drug injectors. J Subst Abuse Treat 2000;19(3):247-‐52.

15. Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health 2000;90(12):1933-‐36.

16. Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr2001;28(3):282-‐8.

17. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2015. HIV Surveillance Report 2016:27. Accessed May 1, 2017. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-‐hiv-‐surveillance-‐ report-‐2015-‐vol-‐27.pdf.

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Harm Reduction: Number of Patients, December 2015-‐September 2017

Total New

0

2000

4000

6000

8000

10000

12000

Syringes Dispensed and Returned, December 2015-‐September 2017

Needles Returned Needles Given

Female;43%

Male;57%

Female

Male

N=2437Unreported 769

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Type of Insurance None Medicaid Medicare Medicare and Medicaid

Private

Type of Insurance

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

<17 18-‐24 25-‐35 36-‐45 46-‐60 >61

Age at first use

N=3188Unreported 18


• 95.8% White• 336 received some combination of Hepatitis B, C, and HIV testing• 35% homeless

Self-‐reported Hepatitis and HIV Status

HBV 20HCV 799HCV/HBV 56HBV/HCV/HIV 1HIV 5


© 2016/2017, Johns Hopkins University. All rights reserved.

Where are Kanawha-Charleston Health Department SSP Clients from?

• From December 2nd, 2015 to April 19th, 2017, there were a total of N=8,716 exchange events at the SSP, among 3,398 unique clients.

• Individuals reported a total of 188 unique zip codes of home residence.

• Reported zip codes were representative of 46 counties in 6 states.

• The SSP serves persons from 29 counties in WV. • 18 were identified by the CDC as vulnerable to HIV/HCV outbreak.

© 2016/2017, Johns Hopkins University. All rights reserved.

Looking ahead…• An ARIMA model was fit using the Box and Jenkins method to monthly counts of syringe distribution.

• An ARIMA (1,1,0) model was determined to be the best fitting model.

• If current rates of syringe distribution continue, we estimate that the Charleston SSP will distribute a total of 487,156 syringes from April 2017 to March 2018.

• This is a 251% increase over the prior 12-month period in which a total of 193,725 syringes were distributed.

Defining the Problem: An epidemic of epidemics• Overdoses• Hepatitis B and C (Hepatitis C is the leading infectious killer in the US)• Soft tissue infections, abscesses, and endocarditis and osteomyelitis• Neonatal abstinence syndrome• Children abandoned, neglected, abused, flooding foster care• Homelessness• First responder compassion fatigue/burnout• Needles in public spaces

Attacking the Problem: All Hands Approach

• More naloxone training and availability• Recovery Point quick survey: Of 165 patients in recovery of ≥ 3 months, 35 had received naloxone

• Quick Reaction Teams (QRT): responding to overdoses• Increase testing for HIV, Hepatitis C, and Hepatitis B• Increase scope and number of harm reduction/syringe service programs• Increase access and availability of long-‐acting reversible contraceptives (LARCs)• Provide more opportunities for safe disposal of syringes

• Syringe deposit boxes• Legislation to declare amnesty for people holding syringes

More…

• Increase access to Hepatitis C treatment, even for active users• Increasing PrEP for HIV in high risk areas• Prevention and treatment of burnout in first responders• Stigma and compassion: treating this problem like any other illness• Looking deeply within ourselves and our society: the epidemic of hopelessness and despair• Demand-‐driven problems won’t be solved by supply-‐restricting solutions.• We’ve tried this before and it was a failure: ”War on Drugs” and Prohibition.

How does this happen?

Adverse Childhood Experiences Study(ACE Study)

• Maybe the most important study of which most Americans are unaware• What is unrecognized in the pediatric exam room shows up in the internal medicine exam room decades later

• Measures 10 categories of childhood abuse and neglect• Abuse (3): Emotional, physical, or sexual• Neglect (2): Emotional or physical• Dysfunction (5):

• One or both biological parents missing from the household• Domestic violence specifically toward the mother • Mental illness in the household• Substance use in the household• Incarcerated members in the household

• http://www.cdc.gov/violenceprevention/acestudy

ACE Questions (1-‐3)

• During your first 18 years of life

1. Did a parent or other adult in the household often ...Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often ... Push, grab, slap, or throw something at you? orEver hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?


4. Did you often feel that ...No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

5. Did you often feel that ...You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?


7. Was your mother or stepmother:Often pushed, grabbed, slapped, or had something thrown at her? orSometimes or often kicked, bitten, hit with a fist, or hit with something hard? orEver repeatedly hit over at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

9. Was a household member depressed or mentally ill or did a household member attempt suicide?

10. Did a household member go to prison?

ACE Study FindingsACE Scores Linked to Physical & Mental Health Problems

• Twice as likely to smoke

• Seven times as likely to be alcoholics

• Six times as likely to have had sex before age 15

• Twice as likely to have cancer or heart disease

• Twelve times more likely to have attempted suicide

• Men with six or more ACEs were 46 times more likely to have injected drugs than men with no history of adverse childhood experiences

Compared with people with no ACEs, those with four or more ACEs were:

Source: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm

10/21/17 28Slide courtesy of Robert Anda and Vincent Felitti

Information from the original ACE Study



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Correlation: Opioid/Heroin Use and ACEs• 1998 ACE study Kaiser Permanente and CDC

• People with ACE ≥ 3: much greater likelihood of engaging in substance abuse, domestic violence and suicidal attempts, were more likely to be obese, to have dropped out of school, be divorced and to have diabetes, cancer and heart disease. ACE ≥ 6: 4600% more likely to use intravenous drugs relative to ACE of zero.

• 2016 study• People with ACE ≥ 5, were 3x more likely to misuse prescription pain medication and 5x more likely to engage in injection drug use.

• 2009 study • over 80% of patients seeking treatment for opioid addiction had at least one form of childhood trauma, with almost 2/3 reporting having witnessed violence in childhood.

• Felitti, V.J. (2003) The origins of addiction: Evidence from the Adverse Childhood Experiences study. Praxis derKinderpsychologie und Kinderspychiatrie, 52, 547 – 559.

• Quinn, K., Boone, L., Scheidell, J.D., Mateau-‐Gelabert, P., Mcgorray, S.Sp., Beharie, N.,Cottler, L.B, and Kahn, M.R (2016) The relationship of childhood trauma and adult prescription pain reliever misuse and injection drug use. Drug and Alcohol Dependence, 169, 190-‐198.

• Sansone, R.A., Whitecar, P., and Wiederman, M.W. (2009) The prevalence of childhood trauma among those seeking buprenorphine treatment. Journal of Addictive Diseases, 28(1), 64-‐67.

http://www.cdc.gov/nccdphp/ACE/index.htm

34

3020

36

19

HRCN = 199

39

26

53

31

28

Comparison betweenthe original ACE study and our survey results

Summary statistics from ACE

• 66% of patients reported at least one ACE event

• 39% patients had a score of 4 or more

• ACEs are more common and severe among patients in the Harm Reduction Clinic than in the referent population.

HRCN=199

33.7

12.6

6.5

8.0

39.2

Primary Prevention

• Addressing the ”Pair of ACEs”• More maternal-‐child programs• Home visitation programs

• Building up communities• Networks of caring adults

• Progress won’t be measured in months or years, but in generations• Requires appropriate resources

Learning from others…

• Today, Iceland tops the European table for the cleanest-‐living teens. • 15-‐ and 16-‐year-‐olds who had been drunk in the previous month: • 42% (1998) to 5% (2016).

• Ever used cannabis: • 17% to 7%.

• Those smoking cigarettes every day: • 23% to 3%.

Documents

All Hands Approach in the Opioid Epidemic …...2017/10/13 · Female; 43% Male; 57% Female Male N=2437 Unreported(769 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Type(ofInsurance None