Lisa Ramirez | Texas Health & Human Services Commission

Lucas Hill | The University of Texas at Austin College of Pharmacy

Mark Kinzly | Texas Overdose Naloxone Initiative

OCTOBER 26, 2018

Innovative Opioid Overdose

Prevention

THE TEXAS TARGETED

OPIOID RESPONSE

Lisa Ramirez

Director of the Texas Targeted Opioid Response

Texas Health & Human Services Commission

State Opioid Response

New funding and project plan update

Accidental Poisoning Deaths in Texas: 1999-2015

4Source: Texas Death Certificates; Accidental Poisonings based on County of OccurrencePrepared by Texas Department of State Health Services, Center for Health Statistics 3/6/2018

2,226

1,174

0

500

1,000

1,500

2,000

2,500

1999 2003 2007 2011 2015

Num

ber

of D

eath

s

Total

Opioids

Cocaine

Psychostimul

ants

Drug Overdose in Texas

• In 2016, 2,799 Texans died due to drug overdose

• More than the population of a Texas 6A high school

• More than the population of nearly 60% of the cities and towns in Texas

5

Sources: CDC (2017). Provisional counts of drug overdose deaths, as of 8/6/2017. Available at: https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdfU.S. Census Bureau (2017). Annual Estimates of the Resident Population in Texas: April 1, 2010 to July 1, 2016. Available at:https://www.census.gov/data/datasets/2016/demo/popest/total-cities-and-towns.html

State Targeted Response

• On May 1, 2017 Texas received $27.4M in federal funding to address the opioid crisis by increasing access to medication assisted treatment (MAT), reducing unmet treatment need, and reducing opioid overdose death through the provision of prevention, treatment, and recovery activities for opioid use disorder.

• Texas received the second highest award in the nation based on unmet treatment need and overdose death rates.

6

Texas Targeted Opioid Response: Core Strategies

7

• Increased access to care and supports

• Reduction of service gaps within the continuum of care

• Increased awareness for the public through education and outreach

Increased Admissions to

Evidence-Based Treatment for OUD

16%

25%

35%37%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Percen

t O

UD

Ad

mis

sio

ns t

o M

AT

2016 2017 2018* TTOR Goal

8* 2018 data incomplete, only three quarters included

Opioid Overdose Reversal Training and Naloxone Distribution

1,702Trained to reverse an opioid overdose

5,910Doses Distributed

82

Lives Savedhttps://www.portseattle.org/sites/default/files/inline-images/DCPRO-CITREP_Banner1.jpg; https://pixabay.com/en/floating-ring-belt-help-lifesaver-160536/; http://core-rems.org/surgeon-general-advises-more-people-to-be-prepared-get-naloxone-save-a-life/

State Opioid Response

SAMHSA released State Opioid Response Grants (SOR), a funding opportunity announcement to extend and expand the funding. • Available grant award originally $45.5M/year increased to

$46.2M/year• Application was submitted August 3, 2018 • Application deadline was August 13, 2018

• Notice of Grant Award received September 19, 2018 at $46.2M/year

• Start date is September 30, 2018

• Service provision must begin no later than December 31, 2018• Grant period is for two years with annual continuation

10

SOR Grant Requirements

• Use epidemiological data to demonstrate gaps in treatment availability

• Utilize evidence based implementation strategies to address gaps

• Deliver evidence based treatment that include FDA approved medications for the treatment of Opioid Use Disorder (OUD) and psychosocial interventions

• Report progress towards increasing availability of MAT and reducing opioid overdose death

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SOR Grant Expectations

• Based on TTOR strategic plan, develop and provide opioid misuse prevention, MAT, and recovery support services for the purpose of addressing the opioid misuse and the overdose crisis

• Only evidence-based treatments, practices, and interventions for OUD may be used by grantees and subgrantees.

• In addition to treatment services, grantees will be required to employ effective prevention and recovery support services to ensure that individuals are receiving a comprehensive array of services across the spectrum of prevention, treatment and recovery.

• SAMHSA will monitor funding to assure that they are being used to support evidence based treatment and recovery support and they will not permit use of funds for non-evidence based approaches.

• Service provision is expected no later than the third month after notice of grant award

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SOR Required Activities

• Assess needs of tribes and include strategies to address them

• Implement models that enable the full spectrum of treatment and recovery support services that facilitate positive outcomes and long term recovery from OUD

• Implement community recovery support including peer support/peer coaching and recovery housing

• Implement prevention and education services including:

• Training of healthcare professionals on the assessment and treatment of OUD

• Training of peers and first responders on opioid overdose and naloxone

• Develop evidence based community prevention efforts

• Purchase and distribute naloxone13

SOR Grant Funding Limitations

• No more than 5% of total grant award may be used for administrative and infrastructure development costs

• Up to 2% may be used for data collection and reporting

• Only FDA approved products may be purchased

• Funds may not be expended by any agency which would deny any individual access to their program due to use of FDA-approved medications for the treatment of substance use disorders. Specifically, patients must be allowed to participate in methadone treatment

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Prevention Strategies

• Opioid Misuse Prevention and Safe Prescribing –HHSC plans to continue support of prescriber education through online training modules aimed at reducing opioid misuse through safe prescribing practices and overdose prevention education.

• Utilization of the Prescription Monitoring Program –HHSC plans to increase prescriber enrollment and meaningful use of the Prescription Monitoring Program to ensure not only patient screening but identification of problematic opioid use and appropriate referral to treatment.

• Safe Drug Disposal and Community Awareness –HHSC will create safe drug disposal initiatives throughout Texas communities and evaluate the effectiveness of safe disposal initiatives in targeted environments with the goal of reducing the availability of unused medications that can lead to opioid misuse.

• Overdose Prevention –HHSC will provide Texas communities with overdose prevention education, access to overdose reversal medication, and overdose reversal tracking tools with the goal of providing timely community response and reducing overdose death.

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Treatment Strategies

• Office Based Opioid Treatment –HHSC will increase access to medication assisted treatment in the office setting by increasing the number of physicians providing medication assisted treatment, expanding opportunities for physicians to obtain DATA 2000 Waiver training, creating a professional peer mentoring network, and expanding the network of state-funded treatment providers.

• Opioid Treatment Services and Treatment for Co-Morbid Conditions – HHSC will increase MAT capacity by expanding opioid treatment services at new and existing sites and enable them to treat both primary opioid use disorder along with co-morbid conditions such as hepatitis C, psychiatric, and wound care at a single site.

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Recovery Support Strategies

• Peer Support –HHSC will expand peer recovery support services throughout the state in a variety of settings and provide opportunities for enhanced training in medication assisted recovery for the peer support workforce.

• Employment Services–HHSC will provide job developer and supported employment services for individuals in medication assisted recovery from opioid use disorders.

• Reentry- HHSC will provide peer support services for individuals at risk for opioid overdose being release from jail. These services include overdose prevention education and access to naloxone, peer recovery support coaching, and linkage to MAT.

• Recovery Housing –HHSC will provide resources to reduce discrimination and increase safe housing for individuals in medication assisted recovery from opioid use disorders

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Integrated Services

• Emergency Response –HHSC will provide individuals identified as being at high risk for overdose and overdose survivors and with treatment induction, recovery support, community paramedicine support, overdose prevention services. In addition, select Mobile Crisis Outreach Teams will provide opioid crisis services.

• Community Access –HHSC will provide access to treatment, recovery support, overdose prevention, and linkage to care through OSAR services and 24/7 community drop-in sites.

• Pre-Arrest Diversion–HHSC will provide 24/7 drop-in pre-arrest diversion services that include treatment induction, recovery support, overdose prevention, and linkage to care.

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Infrastructure Development

• Approximately five percent of the funds will be used to enhance the existing electronic health records system.

• This large-scale and long-term project aims to increase provider enrollment in opioid use disorder service delivery.

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Thank YouLISA RAMIREZ, MA, LCDC| PROJECT DIRECTOR, TEXAS TARGETED OPIOID

RESPONSE

SUBSTANCE USE DISORDER UNIT

Behavioral Health Services Section

8317 Cross Park, Ste. 350 | Austin, Texas 78754

Office: 512-838-4379 Cell: 512-497-4432 Fax: 512-838-4370

lisa.ramirez@hhsc.state.tx.us

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NALOXONE EDUCATION &

DISTRIBUTION

Lucas G. Hill, PharmD, BCPS, BCACP

Clinical Assistant Professor & Director of Operation Naloxone

The University of Texas at Austin College of Pharmacy

Opioid Safety: Focus on Furnishing Naloxone. San Francisco Department of Public Health. https://goo.gl/AcJvAb

Harm Reduction• Practical strategies to reduce the negative consequences of risky behaviors

– Driving = seatbelt

– Cooking = fire extinguisher

– Intercourse = condom

• A spectrum of strategies may be employed in the context of drugs

– Safer use

– Managed use

– Abstinence

Harm Reduction Coalition. Principles of Harm Reduction. http://harmreduction.org/about-us/principles-of-harm-reduction/

Naloxone = the opioid

overdose antidote

• High affinity mu-opioid

receptor antagonist

• Minimal risk for serious

adverse effects

• Multiple formulations

approved by FDA for

layperson administration

Opioid Safety: Focus on Furnishing Naloxone. San Francisco Department of Public Health. https://www.chcf.org/wp-content/uploads/2018/06/OpioidSafetyFocusFurnishingNaloxone.pdf

Continuing education & informational

resources for prescribers, pharmacists,

behavioral health professionals, & patients

Progress

• 1,896 trainees via 53 overdose prevention workshops

• 14,472 doses of naloxone distributed

• 659 healthcare professionals educated via online CE

FENTANYL TEST STRIPS &

SYRINGE ACCESS

Mark L. Kinzly

Co-Founder of the Texas Overdose Naloxone Initiative

“Despite anecdotal reports that

higher-than-usual doses may be

necessary, animal data suggest

that standard doses of naloxone

should be sufficient to reverse

carfentanil.”

ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency First Responders. ACMT Website. Approved July 12, 2017.

Fentanyl test strips are sensitive (96-100%) & specific (90-98%)

People who use drugs indicate they would use differently if their supply tested positive

Fentanyl Overdose Reduction Checking Analysis Study (FORECAST). Bloomberg American Health Initiative. Published 2/6/18.

Zibbell et al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use. Am J Public Health. 2018;108(2):175-81.

Syringe Service Programs. Centers for Disease

Control and Prevention.

https://www.cdc.gov/hiv/risk/ssps.html.

Updated 4/19/18. Accessed 4/29/18.

SSPs offer clear benefits with no

documented harms.

Discrimination and NIMBYism are barriers to

implementation.

Syringe Service Programs and

the Opioid Epidemic. American

Foundation for AIDS Research.

http://www.amfar.org/ssp-

opioid-epidemic/. Published

11/3/17. Accessed 3/30/18.