heroin use disorder in the past year

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BEST PRACTICES: APPLYING SCIENCE & LEVERAGING

EXPERIENCE FOR BETTER HEALTHKimberly Johnson, PhD

Director, Center for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administration

U.S. Department of Health & Human Services

24th Annual New England School of Best Practices in Addiction Treatment

Waterville Valley, NH August 29th, 2016

TODAY’S TOPICS

EPIDEMIOLOGY OF SUBSTANCE USE

EXPANDING ACCESS

IMPROVING QUALITY

EVIDENCE-BASED PRACTICE (EBP)

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EPIDEMIOLOGY OF SUBSTANCE USE:SNAPSHOTS & TRENDS

+ Difference between this estimate and the 2014 estimate is statistically significant at the .05 level.

PAST MONTH ALCOHOL USE

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People Aged 12 or Older by Age Group: 2002-2014

CURRENT, BINGE, AND HEAVY ALCOHOL USE

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People Aged 12 or Older: 2014


YOUTH: CURRENT, BINGE, AND HEAVY ALCOHOL USE

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People Aged 12 to 20: 2002-2014


PAST MONTH ILLICIT DRUG USE

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NUMBER OF PAST MONTH ILLICIT DRUG USERS

Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not includepeople aged 11 years old or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term hospitals.

Note: The estimated numbers of current users of different illicit drugs are not mutually exclusive because people could have used more than one type of illicit drug in the past month. Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically. 9


NUMBER OF PEOPLE WITH A PAST YEAR SUD

SUD = substance use disorder. Note: SUD refers to dependence or abuse in the past year related to the use of alcohol or illicit drugs in that same period.

Estimated numbers of people having disorders for specific substances do not sum to the 21.5 million people with any SUD because people could have disorders associated with their use of more than one substance. 10



ALCOHOL USE DISORDER IN THE PAST YEAR

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ILLICIT DRUG USE DISORDER IN THE PAST YEAR

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MARIJUANA USE DISORDER IN THE PAST YEAR

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CPDs & HEROIN

Controlled prescription drugs (CPDs) and heroin are ranked as the most significant drug threats to the U.S.• Deaths attributable to CPDs

have outpaced those for cocaine and heroin combined.

• A subset of opioid CPD users are initiating heroin use.2015 NDTAS data sources include the DEA,

SAMHSA, CDC, NIDA, & other federal, state, and local data systems. http://www.dea.gov/docs/2015%20NDTA%20Report.pdf

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OPIOID OVERDOSES ARE DRIVING INCREASE

https://www.cdc.gov/drugoverdose/data/statedeaths.html


PAST MONTH NONMEDICAL USE OF PAIN RELIEVERS

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People Aged 12 Or Older By Age Group: 2002-2014


PAST YEAR PAIN RELIEVER INITIATES

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PAST YEAR PAIN RELIEVER USE DISORDER

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32% of individuals with chronic pain (CP)estimated to have addictive disorders.

29-60% of people with opioid addictions report CP.

CP & addiction are dynamic conditions that can fluctuate in intensity over time.

Both require multimodal interventions; and treatment for one may impede or conflict with treatment for the other.

Both have serious consequences if left untreated.

CHRONIC PAIN AND SUDs


PAST MONTH HEROIN USE

* Insufficient data available.

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PEOPLE AGED 12 OR OLDER BY AGE GROUP: 2002-2014


PAST YEAR HEROIN INITIATES

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PEOPLE AGED 12 OR OLDER BY AGE GROUP: 2002-2014


HEROIN USE DISORDER IN THE PAST YEAR

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PEOPLE AGED 12 OR OLDER, BY AGE GROUP

Current data does not unequivocally support a causal link between policies implemented to reduce prescription drug misuse/abuse/diversion and an increase use of heroin.– In the majority of studies, the increase in the rates of

heroin use preceded changes in prescription-opioid policies, and there is no consistent evidence of an association between the implementation of policies related to prescription opioids and increases in the rates of heroin use or deaths, although the data are relatively sparse. Compton, WM et al, N Engl J Med 2016;374:154-63

HEROIN USE & NMU OF RX OPIOIDS (2)

ASSOCIATIONS BETWEEN POLYSUBSTANCE USE AND HEROIN USE

SAMHSA NSDUH Data 2011-2013, CDC Infographic

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ASSOCIATION OF HEROIN ADDICTION RATES & OD DEATHS

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DRUG POISONING MORTALITY BY U.S. COUNTY: 2004 & 2014

Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids. -- CDC

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AGE-ADJUSTED RATES OF DRUG OVERDOSE DEATHS BY STATE, 2014


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DRUG OVERDOSE DEATH RATE INCREASE 2013 TO 2014


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NATIONAL DISCONNECT: OUD TREATMENT & FOLLOW-UP SERVICES

http://www.samhsa.gov/data/sites/default/files/report_2117/ShortReport-2117.pdf

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EXPANDING ACCESS

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EXPANDING ACCESS REQUIRES COORDINATED ACTION ACROSS MULTIPLE SECTORS

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HHS SECRETARY BURWELL’S OPIOID INITIATIVE

Medication-Assisted TreatmentTraining and Educational ResourcesNaloxone

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BUPRENORPHINE FINAL RULE

https://www.federalregister.gov/articles/2016/07/08/2016-16120/medication-assisted-treatment-for-opioid-use-disorders

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CARA 2016

https://www.congress.gov/bill/114th-congress/senate-bill/524/text?

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SECTION 223 DEMONSTRATION PROJECT

http://www.samhsa.gov/section-223

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“WE, AS CLINICIANS, ARE UNIQUELY POSITIONED TO TURN THE TIDE ON THE OPIOID EPIDEMIC.”

BE THE SOLUTION. JOIN THE MOVEMENT: http://turnthetiderx.org/

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https://www.effectivehealthcare.ahrq.gov/ehc/products/636/2225/opioid-use-disorder-draft-report-160513.pdf

TREATMENT MODELS FOR OUD IN PRIMARY CARE SETTINGS

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Using Data to Target Resources

IDENTIFYING HIGH RISK TARGET AREAS FOR OUD SERVICES

IMPROVING DATA: SPARS

SAMHSA’s Performance Accountability AndReporting System (SPARS):• Establish a common data & reporting system for

discretionary grants• Provide programmatic TA on data use for

grantees• Improve grant management; performance

monitoring; quality of services delivered; and health outcomes.

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HSB Landing PageIZJTableau Reader- HSBo.shboard Si ' -Final for '

File Dashboard Window Help. -.. - - - -- - - -- - - - - - - -

. .1 . LSelecta Backgound MapHIV

Health Systems Branch Program Map Top 5 WellServed StatesNewYorlt

CalfforniaTexas

FloridaIllinois

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29

14

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Bottom 10Underserved StatesArkansas

Kentucky

Maryland

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HIVCase rate In the 2014

D 0.0 - 7.3

7.3 - 14.6

14.6 - 22.0D•• 22.0 - 29.3

29.3 - 36.6

[Program• HIV• MAT-POOA

I• SBIRT

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OklahomaWest Virginia

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Gender1.41%

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,. .EE Main Dash EE HNDash USAHN VIHN MPHN GUHN ASHN PRHN DCHN AKHN HIHN USADea AKDea H!Dea DCDea PRDea ASDea GUDea MPDea VIDea USANoP AKNoP

Program Program Discnption FundingAmount

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HIV Human lmmunodelicien<y VIUS 51 964,689 132 27.731 13,770MAT-POOA

Medicaboo-AsSISted Treatment Prescnpbon Drug andOpoood Addicbon

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SBIRT Screenng Brief InterventiOn and Referral to Treatment 103

PROGRAM-LEVEL VIEW (TEAM HIV)

GRANTEE-LEVEL VIEW (mock data)

IMPROVING QUALITY

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SAMHSA’S ALIGNMENT WITH 2015 IOM RECOMMENDATIONS

Report sponsors included SAMHSA, NIH, VA, APA, & NASW.

http://iom.nationalacademies.org/Reports/2015/Psychosocial-Interventions-Mental-Substance-Abuse-Disorders.aspx

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IOM’s ITERATIVE FRAMEWORK FOR DEVELOPING STANDARDS

25http://iom.nationalacademies.org/Reports/2015/Psychosocial-Interventions-Mental-Substance-Abuse-Disorders.aspx

QUALITY MEASURES

http://www.samhsa.gov/data/national-behavioral-health-quality-framework#overview

http://www.qualityforum.org/Publications/2015/

QUALITY CONCERNS: SELECT EXAMPLES

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Residential Rehab Sober Housing Peer support roles and reimbursement

EVIDENCE-BASED TREATMENT

http://www.samhsa.gov/find-help

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EBP IS DATA DRIVEN, CONSTANTLY EVOLVING, AND NECESSARILY ADAPTIVE

http://www.samhsa.gov/ebp-web-guide/substance-abuse-treatment

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EVIDENCE-BASED TREATMENTS:ONE SIZE DOES NOT FIT ALL

Just as individuals vary in their susceptibility tochronic diseases, individuals vary in their responseto treatments. •For some, behavioral & psychosocial

interventions may be effective & sufficient• For others, these interventions may need

to occur in conjunction with medication • Different medications may be more effective

& appropriate for different individuals

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DETOXIFICATION IS NOT SUFFICIENT AS A STAND ALONE TREATMENT

Placebo Controlled Study of Maintenance vs. Detoxification with Buprenorphine

Kaplan-Meier curve of cumulative retention in treatment

Kakko J et al. Lancet.361(9358):662-8.2003.

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MEDICATION ASSISTED TREATMENT

MAT, in principal, is widely used to treat a number of chronic diseases including heart disease and diabetes.• Medications are used where it is determined to

be medically necessary and appropriate.MAT is not a stand-alone treatment choice.

• It is part of an overall EB treatment program that can include behavioral, cognitive, & other interventions.

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Provides effective, evidence-based medicines to treat opiate disorders to help stabilize the physiological & social effects of opiate addiction.• Improves individual – as well as public –

health & safety.• Facilitates recovery, thereby positively

influencing personal well-being and productivity as well as providing net economic benefits for society.

EVIDENCE-BASED OUD MAT

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EBP: METHADONE IMPROVES OUTCOMES

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78%

37%45%

0102030405060708090

100

Buprenorphine Referral Brief Intervention

% e

ngag

ed in

trea

tmen

t on

the

30th

day

afte

r ran

dom

izat

ion

5.4

2.3

Number of days of illicit opiate use per week

5.4

0.9

5.6

2.4

EBP: BUPRENORPHINE IN THE ED

Increased Engagement in Treatment & Reduced Illicit Opioid Use

Data: D’Onofrio, et al. JAMA. 2015.Slide adapted from Dr. W. Compton, 2016.

57Lee JD et al. N Engl J Med 2016;374:1232-1242. Slide adapted from Dr. W. Compton NIDA 2016.

RCT: N=308

EBP: NALTREXONE-XR

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Heroin overdoses Buprenorphine treatmentMethadone treatment

EBP: MAT CAN DECREASE HEROIN OD DEATHS

Baltimore, Maryland, 1995-2009

Schwartz RP et al., Am J Public Health. 2013. Slide adapted from Dr. W. Compton NIDA 2016.

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CSAT’s FY 2016 budget is approximately $2.2 billion.• $1.858 billion for the Substance Abuse

Prevention and Treatment Block Grant (SABG)

• $334 million for CSAT’s discretionary portfolio

SAMHSA CSAT FY16 OPERATING BUDGET

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SELECT CSAT GRANT PROGRAMS

Substance Abuse Prevention and Treatment Block Grant (SABG)

Targeted Capacity Expansion (MAT PDOA; PTP; TAC)

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Opioid Treatment Programs & Regulatory Activities

Criminal Justice Minority AIDS Initiative (MAI)

Pregnant and Post Partum Women

Children and Families

Treatment Systems for Homeless

Recovery Community Services Program (RCSP)

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TCE-MAT TCE-TACTCE-HIVTCE-PTP

TARGETED CAPACITY EXPANSION: FY2016 FOAs

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TECHNOLOGY TRANSFER& WORKFORCE DEVELOPMENT

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Focus on safe opioid prescribing

www.pcss-o.org

Focus on OUDtreatment

www.pcssmat.org

Focus on CME-accredited trainings on

safe use of opioids63

WORKFORCE TRAINING

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WORKFORCE FY2016 FOAs

PCSS-MATMFP-ACSAMHSA-HRSA

http://www.samhsa.gov/grants/grant-announcements-2016

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TELEHEALTH

http://www.asam.org/education/live-online-cme/fundamentals-of-addiction-medicine/recognition-program/teleecho-clinics

OTP SCPMobile AppsECHO

IMPROVING OUTCOMES THROUGH HIT

Content on this slide is for educational purposes only; there is no explicit nor implicit endorsement of services or products.

OTP SERVICE CONTINUITY PROJECT (SCP)

http://blog.samhsa.gov/2015/11/13/providing-otp-services-during-service-disruptions/#.Vw-eGs8XRPP

Use of a Health Information Exchange (HIE) to facilitate the exchange of dosing and associated demographic information between OTPs during a service interruption or a temporary client relocation, in accordance with client preferences.

All activities and systems are compliant with 42 CFR Part 2

MOBILE APPS

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OPIOID RECOVERY APP CHALLENGE

http://samhsaopioidrecoveryapp.devpost.com/


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LEARNING HEALTH CARE SYSTEMS INTEGRATE EBP + PBE

IOM (NAM): Science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral byproduct of the delivery experience.

Combines/integrates: Evidence-Based Practice (EBP) + Practice-Based Evidence (PBE)• Synergistic & dynamic evolution of knowledge,

best practices, and guidelines

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THANK [email protected]

APPLYING SCIENCE & LEVERAGING EXPERIENCEFOR BETTER HEALTH

https://www.recoverymonth.gov/

Documents

heroin use disorder in the past year