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

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

Rachel Solotaroff, MD, MCRMedical Director, Central City ConcernMay 2, 2013

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

Disclosures

No financial relationships to disclose

I am a clinician and colleague; not an expert

I am an incrementalist; not a trailblazer

BACKGROUND

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

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)

OPIATE USE AND ABUSE IN OREGON – WHERE WE STOOD IN 2008

Deaths due to Drug Poisoning in Oregon

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Drug poisoning mortality: rate and frequency by year and select drug type, Oregon, 1999-2008

Number of cocaine deaths

Number of heroin deaths

Number of prescription opioid deaths

Rate of drug poisoning

Oregon Public Health Division- Injury Prevention Program

*2008 mortality data are preliminary; drug death categories are not necessarily mutually exclusive- deaths may involve multiple drugs. Includes unintentional and undetermined drug poisonings. Data source: Oregon Center for Health Statistics mortality data file.

Oregon Health Authority, Office of Disease Prevention and Epidemiology

Hospitalizations

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Unintentional poisoning hospitalization- rate and frequency by drug category and year, Oregon 1997-2007

Other drugs (44 categories combined)

Opioid analgesics (+ methadone)

Rate of unintentional poisoning


Data source: Oregon Hospital Discharge Index


Who’s At Risk?

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Age distribution of prescription opioid deaths, Oregon, 1999-2009



Supportive Housing

The Role of Methadone

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Drug poisoning mortality: the role of methadone, Oregon, 1999-2008

All drug and medication-related deaths combinedAll prescription opioid-related deaths combinedMethadone-related deaths

2008 data are preliminary. Categories are not mutually exclusive- many deaths sumultaneously involve several types of drugs. Includes only deaths with an X40-X44 & Y10-Y14 ICD-10 code for underlying cause of death (unintentional and undetermined intent).

Oregon Injury Prevention ProgramPublic Health Division

Methadone: Grams Sold and Death Rate.

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Note: grams sold on left axis, death rate on right axis

Retail distribution of methadone in Oregon and poisoning mortality rate asociated with methadone in Oregon, 1999-2006

Grams sold/100,000 population

Methadone death rate

Sources: US Dept. of Justice, Drug Enforcement Administration, Of f ice of Diversion Control, Automation of Reports and Consolidated Orders System (ARCOS); Oregon Center for Health Statistics mortality data f iles. Includes unintetnional and undetermined intent deaths.


Factors Among Methadone Decedents

41% prescribed methadone; 30% no RxPrescriptions: 43% pain; 26% methadone

maintenanceIn 77%, abuse contributed to death75% history of substance abuse21% history of substance abuse treatment52% history of mental illness

Sample N=56Oregon Health Authority, Office of Disease Prevention and Epidemiology

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

SAMHSA- 2008, 2013 National Survey on Drug Use and Health, state level data

2008: Oregon is 5th highest state for nonmedical use of prescription painkillers*

6.6% of persons >12 years8.2% of persons 12-17 years17.9% of persons 18-25 years – highest in any US state

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


ADDRESSING THE EPIDEMIC

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

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

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

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”

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

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)

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

Strengthening Our Systems and Supports

Level One

Level Three

Hot Sauce

Weekly

Acupuncture

RENEW

Monthly Group Visits with OT/PCP

Behavioral Health Assessment or Impact

Monthly “Activity Groups”

Primary Care Only

q 2-3 mo visits

Chronic Pain Recovery Pyramid

Level Two

Low addiction risk:•Good self-management•Good support•Good function/activity

Low addiction risk BUT:•Low self-management•Low social supports•Low function/activity

High addiction risk:•Brief relapse •Early Recovery•Minimal support

Graduation Criteria:-- Level 3: completion of Hot Sauce-- Level 2:

Progress toward goals Engaged in Behavioral health (if nec) Reduction in opiate dosage

Risk Management-- UDS – q 3 months-- pill count – q 6 months-- ADR’s – q 3 months-- PDMP: annually

Income &

Employment

Volunteering,Training, Jobs

CP Identified at Intake:

-- ROI’s

-- CP acknowledgemt

-- BH Screen:

•ORT

•PHQ

•GAD-7

• PTSD Screen

OT

Assess

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.

Behavioral Health

Chronic Pain Recovery Program Road Map

PCP Appt #1

PCP Appt #2

4 weeks

If + BH Screen

H&P, Record Review, UDS, OPDMP query

LESSONS LEARNED

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

THANK YOU!

Documents

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