10/14/2019

1

October 17-19, 2019

THANK YOU

2

Name CommercialInterests

RelevantFinancial

Relationships:What WasReceived

RelevantFinancial

Relationships:For What Role

No RelevantFinancial

Relationshipswith Any

CommercialInterests

P. Bradley HallMD

X

Appalachian Addiction & Prescription Drug Abuse ConferenceDISCLOSURES

3

10/14/2019

2

THANK YOU

4

• WV Board of Medicine• WV Board of Osteopathic Medicine• WV Board of Pharmacy• WV Board of Nursing• WV State Medical Association• WV Osteopathic Medical Association• WV Nurses Association• WV Society of Addiction Medicine• CAMC Health Education and Research Institute

•WV Medical Professionals Health Program•WV Pharmacy Recovery Network•WV Restore• Speakers• Attendees

v AAPDAC Staffv Jenny Lancaster, Terzetto Creative, LLC

5

THANK YOU

2019-Appalachian Addiction & Prescription Drug Abuse Conference• West Virginia – The Current “STATE” of Affairs• Stigma of Addiction• The Opioid Crisis – Understanding & Responding to an Epidemic of Addiction• Luncheon Program: Spirituality in Medicine and in Recovery• Nurses Fit to Perform Training• Addiction, Mental Health & Suicide Amongst Professionals• Legislative Update• WV Laws, Rules & Regulations and the CSMP• Evening Speaker: Leaning in to Vulnerability-The Power of the Personal Story for Reducing the Stigma

Around Addiction• Integration of Opioid Addiction Treatment with MAT & 12-Step Programs• Pain & Addiction Treatment – Best Practices• Cognitive Behavioral Therapy in the Treatment of Pain & Addiction• Luncheon Program: Mindfulness in the Treatment of Opioid Use Disorder• From Burnout to Wellness: A Road Map to Engagement• Dinner Program: Never Enough – How Affective Homeostasis Creates Addiction: Marijuana & Opiates• Anxiety & ADHD• Connectivity Addiction – Problematic Internet, Gaming & Social Media• Marijuana / CBD – Fact or Fiction• Understanding Lethality: WV Overdose Statistics

6

10/14/2019

3

AVAILABLE CME CREDITS:• Allopathic Physicians &

Physician Assistants• Podiatrists• Osteopathic Physicians &

Physician Assistants• Social Workers• Psychologists• Registered Nurses (RNs)• Licensed Practical Nurses

(LPNs)• Licensed Professional

Counselor (LPC)

• Dentists• Pharmacists• Addiction Counselors• ABAM Maintenance of

Certification (MOC)• Lawyers• Peer Recovery Support

Specialists***Licensure Board required

3 hours

7

THANK YOU

EXHIBITORS

8

9

~Diamond Level Exhibitor~

FS Solutions

10/14/2019

4

10

The Farley Center

WV Medical Professionals Health Program

WV Society of Addiction Medicine

~Platinum Level Exhibitors~

DrugscanFirst Choice Services, Inc.

MedMark Treatment CentersPavillon

11

~Gold Level Exhibitors~

12

~Silver Level Exhibitors~Ascension Recovery Services

Addiction Healing Center, St. Francis HospitalCornerstone of Recovery

IndiviorQuality Insights

The Safe & Effective Management of Pain GuidelinesWV Health Information Network

10/14/2019

5

13

• AA - Alcoholics Anonymous• Alanon Family Groups• Alkermes Pharmaceuticals• Innovative Health Solutions• IntegraLabs, Inc.• Journey Pure• Lakeview Health• NA - Narcotics Anonymous• Professional Risk Associates• Retreat Behavioral Health• White Deer Run Treatment

Network

• WV Association of Alcoholism &Drug Abuse Counselors

• WV Board of Addiction &Prevention Professionals

• WVU Medicine Center for Hope &Healing

• WVU Medicine Physician &Provider Recruitment

• WV Judicial & Lawyers AssistProgram

• WV Project ECHO• WV Public Transit Association

~Bronze Level Exhibitors~

14

~Break Supporter ~

Arnett Carbis Toothman, LLP

~Lunch Supporter ~

WV Comprehensive Treatment Centers-Acadia Health Care

15

~Dinner Speaker Supporter~

10/14/2019

6

EPIDEMIC

16

17

18

10/14/2019

7

The total costs of drug abuse and addiction dueto use of tobacco, alcohol and illegal drugs areestimated at $740 billion a year Illicit drug usealone accounts for $193 billion in health care,productivity loss, crime, incarceration and drugenforcement.Trends & Statistics | National Institute onDrug Abuse (NIDA)https://www.drugabuse.gov/related-topics/trends-statistics

19

20

57.8 per100,000

974deaths

2017 Drug Overdose Death Rates - WEST VIRGINIA

Pain Patients“Drug Abusers”

63% admitted to using opioids forpurposes other than pain1

35% met DSM V criteria foraddiction2

1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample ReceivingDaily Opioid Therapy. J Pain 2007;8:573-582.

2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.

This is a false dichotomyAberrant drug use behaviors are common in pain patients

92% of opioid OD decedentswere prescribed opioids forchronic pain.

3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description ofDecedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.

10/14/2019

8

22

10.2 Million38.4 Million

SUD & Mental Illness

9.2Million

Mental Illness,NO SUD

SUD, NOMental Illness

19.3 Million w/SUD 47.6 Million w/Mental Illness

PAST YEAR SUD & MENTAL HEALTH ILLNESS: 201857.8 Mil1ion Adults had either SUD or Mental Illness

SAMHSA, NSDUH 2018

Neonatal Abstinence Syndrome

• From October 1, 2016 to May 31, 2017:• 5.3% of all infants born at WV birthing facilities were exposed to drugs prenatally.• 5.6% of WV infants born at in-state birthing facilities were exposed to drugs

prenatally.

23

24

10/14/2019

9

Evolution of an Epidemic1980

Unsubstantiated claims:“Addiction Rare in Patients Treated

with Narcotics”

Porter & Jick. 1980. NEJM. 302(2): 123

25

2018 NSDUH Report Illicit <30 days53.2 Million Adults (19.4%) =1 in 5 Americans!!

• Marijuana – 43.5 million (15.9%)• Prescription Drugs – 16.9 million (6.2%)

• Pain Relievers –9.9 million• Stimulants – 5.1 million• Tranquilizers/Sedatives – 6.4 million

*includes-Benzodiazepines - 5.4 million• Cocaine – 5.5 million (2.3%)• Hallucinogens – 5.6 million (2.0%)• Inhalants – 2.0 million (0.7%)• Methamphetamines – 1.9 million (0.7%)• Heroin - 808,000 (0.3%)

27

10/14/2019

10

Substance of Choice - WVAlcohol 40%

Alcohol + Drugs 34%

Drugs Alone 26%

Drugs of Abuse - WVOpiates 44%Marijuana 12%Amphetamines 0%Benzodiazepines 0%

Polysubstances 44%

28

29

WV versus US

Data Source: WV Health Statistics Center, Vital Surveillance System and CDC WonderRates are adjusted by age to the 2000 US Standard Population

30

10/14/2019

11

NEW FACTORSInflux of Fentanyl analogs

•Transition from Rx opioids to illicit Heroin& Fentanyl

• 80% of new heroin users began withnon-medical use of Rx opioids

• Production of opioid pills containingFentanyl

31

West Virginia TodayEPICENTER

32

Policy Strategies Enacted in WVMaking naloxone available without a prescription or third-party prescribing

Overdose response training for professionals and laypersons and community-basednaloxone education and distribution programs

Good Samaritan laws

PDMP and CME requirements for prescribers

MAT and Pain Clinics

Harm Reduction Programs at community level

Office of Drug Control Policy

33

10/14/2019

12

Controlling the epidemic:A Three-pronged Approach

•Prevent new cases of opioid addiction.

•Treatment for people who are alreadyaddicted

•Supply control- Reduce over-prescribing andblack-market availability.

34

ExperienceCollaboration

CommunicationInformationEducation

AccountabilityNetworking

Funding

35

STIGMA HUMAN

Integration through Inter-professional Education

Relationships1 – Listen to understand, not to reply. This allows

understanding of others’ perspective and openmindedness to new knowledge.

2 – The most dangerous opinion is the highestopinion we hold of our own opinion. This isparticularly true to that which we are sure about.

36

10/14/2019

13

GOOD NEWS

% of 12th graders using Opioids• 9.2 % in 2009• 4.2 % in 2017

37

38

39

10/14/2019

14

• # of written prescriptions for opioidshas decreased 43% since the 2011 peak.

• 34 pills per adult, down from 72 pillsper adult in 2011.

• Too many-too much-too long !

GOOD NEWS

40

41

REVERSING THE EPIDEMIC1. Change Prescribing

• Restrained Rxs• Non-opioid alternatives

2. Pharmacy Oversight3. PHARMA Accountability4. Utilize PMDB5. Early ID of OUD & expand Tx

• MAT• NARCAN

6. Destigmatize addiction7. Improve data collection

42

10/14/2019

15

REVERSING THE EPIDEMIC

8. Expand insurance coverage:• Non-opioid approaches• Non pharmacologic methods

9. Implement harm reduction:• Needle exchanges• Expand NARCAN availability

43

Addiction is the Problem

• Prescription Opioids• Heroin• Amphetamines• Inhalants• Cocaine• Benzodiazepines• Marijuana

44

AddictionThere is No One “Gateway” Drug

•Alcohol, tobacco and marijuana are threegateway drugs for adolescents

•Subsequent opioid use•Drug prevention must not be drug by drug

vIt is about any and all drug use by youth

45

10/14/2019

16

PreventionØPrimary Prevention - avoid the development of

disease **

Ø Secondary Prevention- diagnose and treat anexisting disease in its early stages before significantmorbidity and patient harm

ØTertiary Prevention - treatments aim to reduce thenegative impact of established disease by restoringfunction and reducing disease-relatedcomplications

**Cultural shift through education

46

47

Addiction is the Problem• Mood Altering Substances• Work• Television• Shopping• Gaming• Internet• iPhone• Facebook• Gambling• Food• Sex• Our own opinion, thoughts, feelings & beliefs

*HOLE

48

10/14/2019

17

49

Health and Wellbeing Issues• Life / Work Balance• Satisfaction• Lack of joy / unhappiness• Stress• Distress• Burnout• Behavioral Health (interpersonal)• Mental Health• Physical Health• Substance Use / Addiction• Suicide

* Dis-ease of human-ness

49

•Physical Health•Mental Health•Emotional Health•Spiritual Health

50

Life/Work Balance

Satisfaction

Lack of Joy/Unhappiness

Stress Distress

Burnout

Behavioral Health(interpersonal)

Substance Use/Addiction

Mental Health

Physical Health

Suicide

An example of unhealthy cycle that healthcareprofessionals may experience

PHPs can intervene and help at any point!

51

10/14/2019

18

If you are wondering if you have aproblem, that is a BIG RED FLAG.Social users don’t wonder if they havea problem, they know they do not. Ifyou are still wondering you might wantto cut down on whatever you aredoing. If you are unable to cut down…… call the WVMPHP.

YOU52

53

“ Vision is a personal journey.You tend to collect peoplewhen it is genuine. ”

Robert Knittle

54

Changing a Culture….One individual at a time.

10/14/2019

19

Articles of Interest• Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse

Potential – US, 2003-2017– Mbabazi Kariisa, PhD, Lawrence Scholl, PhD, NanaWilson, PhD, Puja Seth, PhD, Brooke Hoots, PhD

• Opioid Prescriptions Dropped 12% in 2017 as Guidelines Change JenniferBresnick

• Should Physicians Recommend Replacing Opioids with Cannabis?- KeithHumphreys, PhD, Richard Saitz, M.D., MPH

• The Potency of Social Versus Drug Rewards–American Journal of Addictions

• Legislative Changes Affect Opioid Prescribing– WV Board of MedicineNewsletter, Summer 2019, Page 8-12

• Drug and Opioid-Involved Overdose Deaths -US 2013-2017 – Lawrence Scholl,PhD, Puja Seth, PhD, Mbabazi Kariisa, PhC, Nana Wilson, PhD, Grant Baldwin,PhD

55

Articles of Interest• Synthetic Opioid Fast Stats– February 2019 – WV DHHR• Drug Facts – Monitoring the Future Survey: High School and Youth Trends –

NIH-National Institute on Drug Abuse

56

Naloxone: Old Drug, New Life

http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-new-policies.page

http://www.asam.org/advocacy/find-a-policy-statement/view-policy-stataement/public-policy-statements/2014/08/28/use-of-naloxone-for-the-prevention-of-drug-overdose-deaths

http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/

57

10/14/2019

20

Naloxone: Old Drug, New Lifehttp://www.drugabuse.gov/about-nida/noras-

blog/2014/02/naloxone-potential-lifesaver

http://prescribetoprevent.org/wp2015/wp-content/uploads/CA.Detailing_Provider_final.pdf

http://www.pdr.net/drug-summary/naloxone-hydrochloride?druglabelid=777

http://www.nlm.gov/medlineplus/druginfo/meds/a612022.html

https://www.sfdph.org/dph/files/CBHSdocs/NaloxoneTraining_11082012.pdf

58

Naloxone: Old Drug, New Life

http://www.wpic.pitt.edu/oerp/Webcast/A103Webcast.htm

http://prescribetoprevent.com/http://projectlazarus.org/prescribers

http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2014/SMA14-4742

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm

59

THANK YOU

ATTENDEES FOR WHO

YOU ARE AND FOR

WHAT YOU DO

60

Brad Hall

*Lynn Hankes

10/14/2019

21

Sources® National Survey on Drug Use and Health (NSDUH)

https://nsduhweb.rti.org/respweb/homepage.cfm® National Center for Health Statistics (NCHS)

http://www.cdc.gov/nchs/® Epidemiologic Catchment Area (ECA)

http://downloadily.com/docs/epidemiologic-catchment-area-study.html® National Co-Morbidity Survey (NCS)

http://www.nimh.nih.gov/health/topics/ncsr-study/nimh-funded-national-comorbidity-survey-replication-ncs-r-study-mental-illness-exacts-heavy-toll-beginning-in-youth.shtmlhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005614/

® National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)http://www.niaaa.nih.gov/research/guidelines-and-resources/epidemiologic-data

® Drug Abuse Warning Network (DAWN ED)http://www.samhsa.gov/data/DAWN.aspx

® Monitoring the Future Survey (MFS)http://www.drugabuse.gov/monitoring-future-survey-overview-findings-2013

® National Vital Statistics System, Mortality File ;http://www.cdc.gov/nchs/deaths.htm

® National Institute of Drug Abuse (NIDA); http://www.drugabuse.gov/

61

62

P. Bradley Hall, M.D.DABAM, DFASAM, AAMRO, MROCC

Executive Medical DirectorWV Medical Professionals Health Program

4013 Buckhannon Pike

Mount Clare, WV 26408

Phone: 304-933-1030

Cell Phone: 304-677-9283

Email: bhallmd@wvmphp.org

wvsam@hughes.net

Website: www.wvmphp.org