NOTICE OF GOVERNMENT AND LEGISLATIVE RELATIONS …€¦ · WHAT ARE OPIOIDS?-- Opioids: drugs that...
Transcript of NOTICE OF GOVERNMENT AND LEGISLATIVE RELATIONS …€¦ · WHAT ARE OPIOIDS?-- Opioids: drugs that...
NOTICE OF
GOVERNMENT AND LEGISLATIVE RELATIONS COMMITTEE OF THE
GROSSMONT HEALTHCARE DISTRICT
A Government & Legislative Relations Committee Meeting of Grossmont Healthcare District will be held Wednesday, May 23, 2018, 9:00 a.m., at the District Administrative Offices, 9001 Wakarusa Street, La Mesa,
California
AGENDA May 23, 2018 – 9:00 a.m.
A. Call To Order
B. Approval of Agenda
C. Public Comment
D. Reports/Discussion/Possible Action Items
1. Behavioral Health Issues
Discussion of Opioid Epidemic Overview and Solutions
2. Legislative Report
E. Next Meeting
F. Adjourn
THE OPIOID EPIDEMIC:
OVERVIEW AND SOLUTIONS
FOR SAN DIEGO COUNTY
Grossmont Healthcare District – May 7th, 2018
Sayone Thihalolipavan, MD, MPH
Deputy Public Health Officer
County of San Diego Health & Human Services Agency
WHAT ARE OPIOIDS?
- - Opioids: drugs that include heroin, fentanyl, and pain relievers
available legally by prescription, such as oxycodone (OxyContin),
hydrocodone (Vicodin), codeine, morphine, etc.
- - Opioid pain relievers are generally safe when taken for a short time
as prescribed by a doctor, but because they produce euphoria, they
can be misused.
- - Regular use—even as prescribed by a doctor—can lead to
dependence and, when misused, opioid pain relievers can lead to
overdose incidents and deaths.
References: National Institute on Drug Abuse. “Opioids.” NIDA, www.drugabuse.gov/drugs-abuse/opioids.
ADDICTION PHYSIOLOGY
THE HISTORY OF THE PROBLEM
ADDICTION INCREASE
- As aforementioned, with the increase of opioid prescriptions came the increase in
opioid use and abuse.
- Use and abuse opioid use disorder (addiction).
- Opioid use disorder- “a problematic pattern of opioid use that causes significant
impairment or distress. A diagnosis is based on specific criteria such as
unsuccessful efforts to cut down or control use, or use resulting in social
problems and a failure to fulfill obligations at work, school, or home, among
other criteria”
References: “Opioid Overdose.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 Aug.
2017, www.cdc.gov/drugoverdose/opioids/terms.html.
OPIOIDS (NOT A COMPLETE LIST)
Morphine
Heroin
Codeine
Methadone
Tramadol
Meperidine (Demerol)
Oxycodone (OxyContin)
Hydromorphone (Dilaudid)
Oxymorphone
Hydrocdone (Norco, Lortab, Vicodin)
Fentanyl, Fentanyl analogs (Carfentanyl), Novel substances (Kratom)
-50x
MAGNITUDE OF THE PROBLEM
115 Americans die from an opioid overdose each .
More than 1,000 Americans are treated in the emergency
department for misusing prescription opioids each .
183,000 people--have lost their lives to prescription
opioids this .
References: “Opioid Overdose.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Aug.
2017, www.cdc.gov/drugoverdose/epidemic/index.html.
Answers: Day, Day, Century
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MAGNITUDE OF THE PROBLEM
References: “The US Opioid Epidemic.” Assistant Secretary for Public Affairs (ASPA), Health & Human Services, Jan 2018,
https://www.hhs.gov/opioids/about-the-epidemic/index.html
THE SCALE OF THE PROBLEM
Approximately
125 MILLION
opioid pills were sold
in San Diego County in 2016
(almost 38 pills per person)
CALIFORNIA OPIOID DASHBOARD
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ZIP CODE DEATHS
Opioids -91962 (Pine Valley)
Heroin – 91962
All drugs - 92134 (Balboa Park
- Naval Medical Center)
Methadone – 92058 (Camp
Pendleton)
Benzodiazepine - 92059
(Pala)
ZIP CODE RX
Buprenorphine – 92121
(Sorrento Valley)
Opioid+Benzodiazepine-91905
(Campo, Jacumba)
New Start LA Opioids – 91905https://pdop.shinyapps.io/ODdash_v1/
HOW WE GOT HERE
When used properly, medicines are important in healthcare
Opioids used to be reserved for “the most severe forms of pain”, such as cancer and end
of life care
Changes in recognition and treatment for pain
In the late 1990’s, opioid prescribing changed for chronic pain (patient bill of rights, 5th vital sign,
decade of pain control and research, CA pain management standards)
These changes, coupled with the multi-million $$$ advertising campaigns (including direct to
consumer) and lobbying efforts by the pharmaceutical agencies, led to the [more] commonplace
prescribing of and use of opioids
References: Franklin GM. Opioids for Chronic NonCancer Pain: a Position Paper of the American Academy Of Neurology.
Neurology. 2014;83:1277-1284.
WHO’S AT RISK FOR MISUSE
Risk factors for opioid misuse or addiction include past or current substance abuse,
untreated psychiatric disorders, younger age, and social or family environments that
encourage misuse.
References: Webster, Lynn R. “Risk Factors for Opioid-Use Disorder and Overdose.” Anesthesia & Analgesia, vol. 125, no. 5, 2017,
pp. 1741–1748., doi:10.1213/ane.0000000000002496. Infographic: CDC, https://www.cdc.gov/drugoverdose/opioids/prescribed.html
OPIOID OVERDOSE DEATH RATE, 2010-2015
References: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death
1999-2015 on CDC WONDER Online Database, released December, 2016. Data are from the Multiple Cause of Death Files,
1999-2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
Accessed at http://wonder.cdc.gov/mcd-icd10.html on Oct 26, 2017 3:18:59 PM
SAN DIEGO COUNTY
REGION COMPARISONS
- In 2015,
Central
Region,
followed by
East Region,
had the
highest rates
of deaths due
to Overdoses/
Poisonings.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
-NOTE: Opioid death rates at geographies lower than County levels are not available in 2011-2015.
OPIOID ABUSE, SAN DIEGO COUNTY 2011-15
REGION COMPARISONS: TOTAL RATES
- In 2015,
Central
Region,
followed by
East Region,
had the
highest rates
of ED
Discharges
due to Opioid
Abuse.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
- In 2015, East
Region,
followed by
Central
Region, had
the highest
rates of
hospitalizatio
ns due to
Opioid
Abuse.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: TOTAL RATES
REGION COMPARISONS: TOTAL RATES
- In 2015, East
Region,
followed by
Central
Region, had
the highest
rates of in-
patient
treatment
discharges
due to Opioid
Abuse.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
OPIOID TOTAL RATES WITHIN EAST REGION:
East Region had higher rates of every medical encounter due to Opioid Abuse, compared
to the County overall.
ED Discharge Rate
San Diego County: 37.1
East Region: 42.3
El Cajon at 48.0 / Lakeside at
47.9
Hospitalization Rate
San Diego County: 14.6
East Region: 27.1
Lakeside at 39.8 / Lemon Grove
at 36.0
In-Patient Treatment
Rate
San Diego County: 10.0
East Region: 14.6
Laguna-Pine Valley at 131.6 (small pop size)
Rates are per 100,000 population.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health
Services, Community Health Statistics Unit, 2018
SRA’s with
Highest
Rates
REGION COMPARISONS: RATES BY AGE
- In 2015, East
Region had
the highest
rates of ED
Discharges
due to
Opioid
Abuse in
those aged
15-24 and 25-
44.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
- In 2015, East
Region had
the highest
rates of
hospital
discharges
due to Opioid
Abuse in
those aged
45-64,
followed by
65+.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: RATES BY AGE
REGION COMPARISONS: RATES BY AGE
- In 2015, East
Region had
the highest
rates of in-
patient
treatment
discharges
due to Opioid
Abuse in
those aged
15-24.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: RATES BY GENDER
- In 2015, East
Region had
the highest
rates of ED
Discharges
due to
Opioid
Abuse in
males.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
- In 2015, East
Region had
the highest
rates of
hospital
discharges
due to Opioid
Abuse in
males.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: RATES BY GENDER
REGION COMPARISONS: RATES BY GENDER
- In 2015, East
Region had
the highest
rates of in-
patient
treatment
discharges
due to Opioid
Abuse in
males.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: RATES BY RACE / ETHNICITY
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
- In 2015, East Region had the highest rates of ED Discharges due
to Opioid Abuse in those identifying as Other Race/Ethnicity (2 or
more races or of unknown race), followed by Black.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
REGION COMPARISONS: RATES BY RACE / ETHNICITY
- In 2015, East Region had the highest rates of hospital discharges
due to Opioid Abuse in those identifying as Other Race/Ethnicity
(2 or more races or of unknown race), followed by White.
REGION COMPARISONS: RATES BY RACE / ETHNICITY
- In 2015, East Region had the highest rates of in-patient treatment
discharges due to Opioid Abuse in those identifying as Other
Race/Ethnicity (2 or more races or of unknown race), followed by White.
Source: Community Health Profiles; County of San Diego, Health and Human Services Agency, Public Health Services,
Community Health Statistics Unit, 2018
SAN DIEGO COUNTY
WHAT IS BEING DONE
PRESCRIPTION OPIOID MISUSE & OVERDOSE PREVENTION WORKGROUP
- State agency formed in 2014 by CDPH Director to share information and develop collaborative
strategies to curb Rx drug misuse, abuse, and overdose deaths
- Includes CDPH, DOJ, DHCS, Managed Health Care, Dept. of Education, Industrial Relations,
Corrections and Rehabilitation, Consumer Affairs, EMS, and others
- Partnered with CHCF who established the Opioid Safety Coalitions Network (network of 17 local
coalitions in 24 counties)
- Commission declared the opioid epidemic a public health emergency
PRESIDENT’S COMMISSION ON COMBATING DRUG ADDICTION AND THE
OPIOID CRISIS
SAN DIEGO COUNTY PRESCRIPTION DRUG ABUSE TASK FORCE
- Formed in 2008 with representation from local/federal agencies to prevent/reduce OxyContin abuse.
- Expanded from there to today’s Prescription Drug Abuse Task Force.
- Includes pain specialists, internal medicine physicians, emergency physicians, psychiatrists,
dentists, pharmacists, hospital administrators, health department administrators, and the local DEA
NA
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SAN DIEGO COUNTY PRESCRIPTION DRUG ABUSE TASK FORCE
Aim: Promote healthy choices about prescription drugs
Based on five pillars of action:
Media
Education (includes medical community)
Enforcement
Legislation and Policy
Prevention and Treatment
PDATF STRUCTURE
ANNUAL REPORT CARD
EMERGENCY AND URGENT CARE GUIDELINES
Safe Prescribing
Intervene in Poor
Prescribing
SAN DIEGO DEATH DIARIES
254 deaths with prescribed
medications in 2013
186 received prescription in the
12 months prior to their death as
reported in Controlled Substance
Utilization Review and Evaluation
System (CURES)
80% have multiple medications
Only 28% doctor shoppers
69% chronic users
16.5% “compliant”
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186
68 CURESData
No CURES
254 deaths +
12 month Prescription data before death
http://www.sandiegouniontribune.com/news/public-safety/sd-me-death-
diaries-20170106-story.html
THE PRESCRIBERS
713 total
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Pain3%
Dentistry4% Surgery
8%
Psychiatry11%
Emergency/Urgent Care
20%
Primary Care54%
PRIMARY CARE
the majority of prescriptions
EMERGENCY PHYSICIANS
many people who die visit ED before
death, many doctors – few prescriptions
PSYCHIATRISTS
#2 in terms of highest number of
prescriptions
SURGEONS
Highest number of pills per prescription
(189 pill average for orthopedics)
IT’S NOT JUST OPIOIDS!
Hydrocodone 123 Chloriazepoxide 17 Oxazepam 3Oxycodone 84 Tempazepam 17 Oxymorphone 3
Clonazepam 44 Methadone 14 Phenobarbitol 3Zolpidem 43 Fentanyl 13 ChloralHydrate 2Alprazolam 39 Buprenorphine 11 Dronabinol 2Lorazepam 37 Amphetamine 7 Zaleplon 2Morphine 32 Testosterone 6 Clorazepate 1Carisoprodol 30 Triazolam 6 Estrogen 1
Codeine 27 Lunesta 4 Lisdexamefetamine 1Diazepam 26 Lyrica 4 Methylphenidate 1Hydromorphone 20 Phentermine 4
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OPIOIDS BENZODIAZEPINES SLEEP STIMULANTS OTHER
33 Medications; 4366 Rx
NALOXONE
• 50 morphine equivalents/day
• Opioid + Benzodiazepine
Naloxone Distribution Grant
• State grant to allow health departments to set up
infrastructure for naloxone distribution programs and provide
naloxone
Image from https://www.drugs.com/pro/naloxone.html
Like giving an
Epi Pen to a patient
with allergies.
LOCAL COALITIONS TO ADDRESS OPIOID MISUSE AND ABUSE
• State grant to PDATF via SDC Medical Society focusing on
East County, 6/2017 – 2/2019
• Goals are to
• Increase safe prescribing, co-prescribing with naloxone,
and use of CURES
• Increase referral to medication-assisted treatment
• Decrease number and quantity of opioid prescriptions,
ED visits, and deaths
• Achieved by academic detailing to providers and
pharmacies, creating and disseminating tools/resources
https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/SACB/Pages/StatewideOpioidSafetyWorkgroup.aspx
WHAT CAN GHC CONSIDER?
• Activate the medical community as a force to prevent
prescription drug misuse, addiction and death in San Diego
County by influencing systems and providers to:
• Follow CDC safe prescribing guidelines and be aware of
other resources (i.e., tapering pocket guide, app)
• Routinely provide or refer to Medication-Assisted Treatment
• Adopt a voluntary Patient Pain Medication Agreement
• Check and input data into CURES (Prescription Drug
Monitoring Program)
• Partner with pharmacies to ensure patients are educated
on potential adverse effects and how to use naloxone
• Attend PDATF and medical PDATF meetings (if not already)
https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/SACB/CDPH%20Document%20Li
brary/OpioidPrescribersResources.pdf
https://www.cdc.gov/drugoverdose/prescribing/clinical-tools.html
QUESTIONS ?
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For more information contact:
Sayone Thihalolipavan, MD, MPHDeputy Public Health Officer
Public Health Services
County of San Diego Health and Human Services Agency
3851 Rosecrans Street (MS-P578)
San Diego, CA 92110
Phone: (619) 542-4916
Email: [email protected]
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