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Physicians Engagedin Prevention
Presenters:
• Yngvild Olsen, MD, MPH, Medical Director, Institutes for Behavior Resources, Inc.
• Daniel Raymond, Policy Director, Government Relations Manager, Harm Reduction Coalition
• Angela Conover, Director, Media and Community Relations, Partnership for a Drug-Free New Jersey
Advocacy Track
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx and Heroin Summit National Advisory Board
Disclosures
Angela Conover; Yngvild Olsen, MD, MPH; Daniel Raymond; and have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
Disclosures
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center
Learning Objectives
1. Specify roles for physicians and medical professionals in responding to the nation’s Rx drug abuse epidemic.
2. Explain how policies supporting PDMP, MAT and naloxone access can work together to reduce opioid abuse.
3. Describe a state program that educates physicians about Rx drug abuse and its link to heroin abuse and engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of the treatment team.
Advocacy Track: Physicians Engaged in Prevention
Yngvild Olsen, MD, MPHMedical Director
Institutes for Behavior Resources, Inc. American Society of Addiction Medicine (ASAM)
Chair, Public Policy Committee
DISCLOSURES
Yngvild Olsen, MD, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Objectives1. Specify roles for physicians and medical professionals in responding to the nation’s Rx drug use epidemic.
2. Explain how policies supporting PDMP, MAT and naloxone access can work together to reduce opioid misuse and addiction.
3. Describe a state program that educates physicians about Rx drug use and its link to heroin addiction and engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of the treatment team.
Multiple Points for Intervention
Recovery
1. Prevention
4. Overdose
Response
Program/Naloxone
3. TREATMENT and RECOVERY
SUPPORT SERVICES
3. TREATMENT and RECOVERY
SUPPORT SERVICES
2. Screening
Safer Opioid Prescribing
• Prescription Drug Monitoring Programs
• CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016
• CME requirements for chronic pain/opioid prescribing
Prescription Drug Monitoring Program (PDMP)
• PDMP Center of Excellence at Brandeis University:– “Evidence continues to accumulate that prescription drug monitoring
programs (PDMPs) are effective in improving clinical decision-making, reducing doctor shopping and diversion of controlled substances, and assisting in other efforts to curb the prescription drug abuse epidemic.”
1 Prescription Drug Monitoring Program Center of Excellence at Brandeis, Briefing on PDMP Effectiveness, Updated
September 2014.
http://www.pdmpexcellence.org/sites/all/pdfs/Briefing%20on%20PDMP%20Effectiveness%203rd%20revision.pdf
Understanding Risk Factors for Addiction
Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services
Screening (and Assessment)
• Goals:
– Identify aberrant medication related behaviors
– Screening for presence of diagnostic criteria for opioid use disorder related to prescription opioids
• SBIRT (Screening, Brief Intervention, Referral to Treatment)
• Multiple screening instruments
Substance Use Disorder Diagnostic Criteria, DSM-V
Severity measured by number of symptoms; 2-3 mild,
4-6 moderate, 7-11 severe
More use than intended Excessive time spent in acquisition
Unsuccessful efforts to cut downCraving for the substance
Activities given up because of useContinued use despite consistent social
or interpersonal problems
Failure to fulfill major role obligations Tolerance*
Use despite negative effects Withdrawal*
Recurrent use in hazardous situations
• These do not apply if the medication is prescribed and no other diagnostic
criteria are met
Addiction Definition
– A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.*
– A chronic, relapsing disease characterized by compulsive drug seeking and use despite harmful consequences as well as neurochemical and molecular changes in the brain.**
*American Society of Addiction Medicine
**National Institute on Drug Abuse (NIDA)
Chronic Disease
• No cure!
• Goal is life long management
• Disease severity may change over time but risk of symptom recurrence is always present
• Effective treatment often combines medications and behavioral interventions
• Behavior change is a key part of management
• Behavior change occurs in stages
Agonist Treatment & Relationship to Heroin Overdose Deaths
Patients in Methadone Treatment
Heroin Overdose Deaths
Patients in BUP Treatment
1995 1997 1999 2001 2003 2005 2007 20090
2000
4000
6000
8000
10000
12000
0
100
200
300
400
Ove
rdo
se
Dea
ths P
atie
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Schwartz, et al., American Journal of Public Health, 2013
Boston Medical and Surgical Journal,
October, 1916
Back to the Future…
Why Is It So Hard to Engage Healthcare Professionals in Addiction Treatment?• Deep historical barriers
– 1914 -1935: Shift in public perception, legal framework, and medical involvement in addiction treatment: Addiction criminalized
– 1920 – 1970: Addiction seen as moral failing – 1974: First legal recognition of opioid agonist therapy to treat
opioid use disorder but created separate DEA classification for physicians who dispense opioids for addiction treatment
• Stigma• New opportunities but little training
– 2000-2002: Drug Addiction Treatment Act (DATA 2000) and buprenorphine approval
– 2006 and 2010: FDA approval of injectable naltrexone for alcohol use disorder and then opioid use disorder relapse prevention
– No universal addiction training in medical school
Treatment need for opioid abuse or dependence exceeds capacity for opioid agonist medication assisted treatment
Source: Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and state treatment need and capacity for opioid agonist medication assisted treatment. AJPH. 2015
Naloxone Co-Prescribing
• Saves lives
• Easy to prescribe
• Little data to guide who should get it
• Recommended for those at high risk of overdose– History of overdose and/or addiction
– High doses of opioids
– Complicating medical conditions
– Low opioid tolerance at risk for resuming opioids
– High risk medication combinations
Naloxone Saves Lives!
Walley AY et al. BMJ 2013;346:f174
ResourcesASAM National Practice Guideline for the Use of
Medications in the Treatment of Addiction Involving Opioid Use
http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/national-practice-guideline.pdf
PCSS-MAT and PCSS-Ohttp://pcssmat.org/http://pcss-o.org/
Three key policies that need to work together to end the opioid crisis:
PDMPs, MAT, naloxone
Daniel Raymond, Policy Director
Harm Reduction Coalition
www.harmreduction.org
Disclosure statement
Daniel Raymond has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
42 States Have Naloxone Access Laws
Source: LawAtlas Policy Surveillance Report, LawAtlas.org, PHLR
4 Quadrants Framework for Naloxone Access
Community1st
Responders
Prescribers Pharmacies
Community-based Overdose Education & Naloxone Distribution (OEND)
• Pioneered in the late ‘90s by harm reduction programs reaching out-of-treatment heroin users
• Diverse settings: syringe exchange, health departments, recovery organizations, parents groups, drug treatment, drug courts….
• Largest evidence base: feasibility, acceptability, impact, cost-effectiveness
• Through June 2014, OENDs provided over 150,000 naloxone kits & received reports of 26,463 overdose reversals
OEND programs as of June 2014
Wheeler E, Jones TS, Gilbert MK, Davidson PJ; Centers for Disease Control and Prevention (CDC). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jun 19;64(23):631-5.
First responders & law enforcement
• Basic EMS (vs. Advanced) more common in rural areas (high overdose rates), but traditionally scope of practice has not allowed them to administer medications – now shifting to allow for naloxone
• Rapid uptake of naloxone by law enforcement (Department of Justice toolkit; grant support in Comprehensive Addiction & Recovery Act)
Naloxone Prescribing
Influential early adopters of naloxone prescribing to at-risk patients:
• Project Lazarus in North Carolina integrated naloxone co-prescribing for patients receiving opioids into a broader overdose prevention and opioid safety initiative
• The Veterans Administration Opioid Overdose Education and Naloxone Distribution programs have provided trained and naloxone to over 12,000 veterans as of December 2015
Naloxone Prescribing Levels Low
Jones CM, Lurie PG, Compton WM. Increase in Naloxone Prescriptions Dispensed in US Retail Pharmacies Since 2013. Am J Public Health. 2016 Apr;106(4):689-90.
Approaches to Naloxone Prescribing
• CDC Opioid Prescribing Guidelines: “consider offering naloxone when prescribing opioids to patients at increased risk for overdose”
• Prescribe to Prevent: http://prescribetoprevent.org/
• Opioid safety vs. overdose – San Francisco Department of Public Health naloxone co-prescription academic detailing
Pharmacy access to naloxone
• Naloxone remains a prescription drug, but can be dispensed by pharmacists under some circumstances
• Pharmacy access to naloxone possible in many states under standing orders or collaborative practice agreements
• Large chains & independent pharmacies moving quickly in many states
• On-going dialogue about whether naloxone could/should be over-the-counter
“Over the Counter” Naloxone Access, Explained, Corey Davis, 3/1/16, https://www.networkforphl.org/the_network_blog/2016/03/01/745/over_the_counter_naloxone_access_explainedOTC Opioid Overdose Antidote: Why is it not FDA Approved?, Zachary Brennan, 2/24/16, http://www.raps.org/Regulatory-Focus/News/2016/02/24/24400/OTC-Opioid-Overdose-Antidote-Why-is-it-not-FDA-Approved/
Opportunities for Advocacy
• Individual doctors have been instrumental in supporting growth of community-based OENDs
• State medical societies provide valuable support for state legislation
• Doctors can education patients & partners on naloxone, champion naloxone prescribing
• Partner with community groups for increased impact on awareness, access, advocacy
Advocacy Track: Physicians Engaged in Prevention
Angela Conover, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
Learning Objectives:1. Specify roles for physicians and medical professionals in
responding to the nation’s Rx drug abuse epidemic.2. Explain how policies supporting PDMP, MAT and
naloxone access can work together to reduce opioid abuse.
3. Describe a state program that educates physicians about Rx drug abuse and its link to heroin abuse and engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of the treatment team.
Who We Are
Opiate Abuse In New JerseyCurrent Drug Trends
Engaging Stakeholders
• Law Enforcement
• Physicians
• Faith Based Leaders
• Community Prevention Agencies
Accessing the Need and Building Capacity
Provide Information
Build Skills Provide SupportReduce Barriers
and Enhance Access
Change Consequences
Change Physical Design
Modify Policy
CADCA’s Seven Strategies to Effect Community-Level Change
CADCA: Community Anti-Drug Coalitions of America
Utilizing Prevention Science
Do No Harm OverviewHackensack University Medical Center
Hackensack, Bergen County, NJOctober 30, 2013
Morristown Medical CenterMorristown, Morris County, NJ
June 10, 2014
Community Medical CenterToms River, Ocean County, NJ
June 11, 2014
Cooper University Hospital Camden, Camden County, NJ
June 12, 2014
Robert Wood Johnson University HospitalNew Brunswick, Middlesex County, NJ
October 1, 2014
Morris County Correctional FacilityMorristown, Morris County, NJ
April 30, 2015
Jersey Shore University Medical CenterNeptune, Monmouth County, NJ
June 10, 2015
Capital HealthHopewell, Mercer County, NJ
November 7, 2015
New Jersey Dental AssociationLivingston, Essex County, NJ
November 13, 2015
0
50
100
150
200
250
300
Total Do No Harm Medical/DentalAttendance: 1,578
0%10%20%30%40%50%60%70%80%90%
100%
Percentages of prescribers who intend to make opioid prescribing
changes or apply learnings to their practice as a result of attending
the Do No Harm Symposium
Earned Media
Recognition:National Association of Government CommunicatorsWhite House Office of National Drug Control Strategy
Provide Information
Build Skills Provide SupportReduce Barriers
and Enhance Access
Change Consequences
Change Physical Design
Modify Policy
CADCA’s Seven Strategies to Effect Community-Level Change
CADCA: Community Anti-Drug Coalitions of America
Utilizing Prevention Science
Physicians Engagedin Prevention
Presenters:
• Yngvild Olsen, MD, MPH, Medical Director, Institutes for Behavior Resources, Inc.
• Daniel Raymond, Policy Director, Government Relations Manager, Harm Reduction Coalition
• Angela Conover, Director, Media and Community Relations, Partnership for a Drug-Free New Jersey
Advocacy Track
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney, American Medical Association Advocacy Resource Center, and Member, Rx and Heroin Summit National Advisory Board
