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The USET/Mohegan Tribe’sPrescription Opiate Abuse Project

Presenters:

• Irene Miller, NP; Director of Family Services

• Charles “Two Bears” Strickland, Vice Chairman; The Mohegan Tribe Council of Elders

Many individuals and agencies contributed to this audit of The Mohegan Tribal Community and its response to prescription opiate abuse. A special thank you is extended to:

Chief Lynn “Many Hearts” Malerba

Council Chairman Kevin “Red Eagle” Brown

Council Member Mark “Matahgha” Brown

Jeff Hotsky, Chief of Mohegan Police

Connie Hilbert, Executive Director of Health and Human Services

Khristine Lariviere, Mohegan Pharmacy Manager

Carrie Janus, Purchased/Referred Care Manager

ACKNOWLEDGEMENTS

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We would also like to thank the numerous Mohegan tribal members who participated in focus groups and individual interviews. Their willingness to share their experiences with substance abuse disorders and chronic pain and their journeys of recovery proved informative and enlightening.

Project Team:

Audrey Allen, NP; Adult and Adolescent TherapistRichard Bennink, LCSW; Adult and Adolescent TherapistEric “Kokchí is ín” Maynard, Sober House & Recovery CoordinatorIrene Miller, NP; Director of Family ServicesCharles “Two Bears” Strickland, Vice Chairman of the Council of Elders Donna Van Sickle, Behavioral Health Clinical Services Office Coordinator

In Appreciation:

Our thanks to Christy Duke, MPH and Kate Grismala, MS of USET, Inc. for their role in making this study possible.

We also want to recognize the contributions and support from the USET Social Services Committee.

ACKNOWLEDGEMENTS (Continued)

PRESCRIPTION OPIATE ABUSE PROJECT

• Introduction

• Praxis Model

• Gaps

• Integrated Model

• Best Practices

• Chronic Pain

• Opioid Addiction

• Pain Management and Addiction

• Recommendations

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• Prescription opiate abuse has reached epidemic proportions

• In the past 20 years the number of written prescriptions for opiates has tripled

• Opioid related deaths have also tripled in that time period

• Native Americans have the second highest death rate from opiate overdoses

• The Mohegan Tribe is located in Connecticut. Between 1997 and 2007 in Connecticut 2,900 drug intoxication deaths occurred; 77% involved opiates (reported for all races)

• Methadone, oxycodone and fentanyl most cited

• The American Academy of Pain Medicine reported that on average opiates help with pain 58% of the time

INTRODUCTION

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The study completed by The Mohegan Tribe addressed prescription opiate abuse among tribal members and their families.

The framework for this project was based on the Praxis Model:

• Description of Praxis Model

• Components of Praxis Model

• Description of Methodology

• Gaps

PROJECT

AUDIT QUESTIONS

1.Is the Tribe adequately addressing prescription opiate abuse?

2. Are we helping our tribal members with drug abuse and addiction?

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Gaps were found in four areas:

1. Education

• Provider

• Client

• Family

• Community

2. Finance

• Methadone Clinic Payment

• Policies

GAPS

GAPS (CONTINUED)

3. Coordination of Care

• Inconsistent use of the PDMP

• Pharmacies

• Providers

• Over-prescribing; lack of following best practices

4. Culturally Appropriate Care

• Lack of culturally focused rehab options

• Lack of training/education for substance abuse certification

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FAMILY SERVICES INTEGRATED MODEL

Our approach to addiction and co-occurring illness:

• Integrated western and culturally based traditional healing practices

• Make up of the Substance Abuse Team is critical to success

• Native and non-Native staff who have made efforts to learn and understand each other’s approaches to healing

• Above helps us to develop a treatment plan that best fits the individual’s needs and preferences

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PAIN

Pain is difficult to measure, subjective, and may be physical, spiritual and/or emotional. There are also cultural overlays of how to express pain, to whom and where.

The focus of this study is on chronic pain as opposed to acute pain, which by definition lasts longer than six months. A simpler definition for chronic or persistent pain is pain that continues when it should not. (International Association for the Study of Pain, 2004)

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Chronic Pain: Evidence Based Practice

• Interdisciplinary team approach

• Complete evaluation

• Patient pain scales

• Provider requirements with opiate prescribing

• Non-pharmaceutical approaches

• Mental health components

• Pharmacological intervention

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Opioid Addiction: Evidence Based Practice

• Screenings

• CAGE-AID test for Opiate Risk

• SASSI (Substance Abuse Subtle Screening Inventory)

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

• Range of treatment options

• Comprehensive assessment

• Frequent modification of plan

• Various modalities

• Medication assisted treatment

Pain Management and Addictions: Evidence Based Practice

• Elements of opioid agreements

• Drug monitoring program

• Physical therapy

• TENS (Transcutaneous Electrical Nerve Stimulation Unit)

• Acupuncture

• Massage

• Meditation

• Cognitive Behavioral Therapy

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Recommendations

1. Interdisciplinary team2. Individualized plan3. Thorough diagnostic work-up4. Mental health evaluation5. Culturally-based healing6. Treatment contracts7. Alternative non-pharmaceutical options8. Medication-assisted treatment9. Follow-up treatment10.Community education regarding opiates and addiction11.Provider education12.Pain clinic laws13.Prescription Drug Monitoring Program14.Substance abuse certification training15.Pharmacy and therapeutics committee

The following are websites where additional information can be found regarding prescription opiate abuse and its management:

Center for Substance Abuse Treatment (CSAT)http://www.samhsa.gov/about/csat.aspxNational Alliance of Advocates for buprenorphine treatmenthttp://www.naabt.orgNational Alliance of Methadone Advocateshttp://www.methadone.orgNational Institute of Drug Abuse NIDAMEDhttp://www.doc.comInteractive teaching videos for doctors, e-learning prescription drug abuseNational Institute of Health and Drug Abusehttp://www.nida.nih.gov/tib/prescriptionProviders Clinical Support System for Opioid Therapieshttp://www.pcss-o.orgProviders Clinical Support System- Medication Assisted Treatmenthttp://www.pcssmat.orgMedication assisted treatment is a project that provides training, mentoring and going educational activities for those offering office-based treatment of opioid dependence.

Additional Information

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