SAMHSA/HHS: An Update, Including the Opioid Crisis › sites › default › files ›...
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Jon Perez, Ph.D. Regional Administrator HHS IX Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services SAMHSA/HHS: An Update, Including the Opioid Crisis PAIHS Integrated Care Summit 5-15-18
Transcript of SAMHSA/HHS: An Update, Including the Opioid Crisis › sites › default › files ›...
Jon Perez, Ph.D.Regional Administrator HHS IX
Substance Abuse and Mental Health Services AdministrationU.S. Department of Health and Human Services
SAMHSA/HHS: An Update, Including the Opioid Crisis
PAIHS Integrated Care Summit5-15-18
Serious Mental Illness:
• In 2016: Over 11 million adults with SMI and over 7 million children and youth with SED
• 35.2% of adults with SMI did not receive mental health treatment
• Lack of use of evidence-based practices: Nearly a third receive medications only with no psychosocial or psychotherapeutic services
• Only 2.1% receive AOT and 2.1% receive supported employment services
• 2 million people are incarcerated every year; 20% SMI and up to 50% with SUD; only 1/3 of those will get any treatment for mental illness
• Creates a revolving door of incapacity, with consequences of inability to be stably housed or employed
• Higher rates of suicide – people with serious depression and/or psychotic disorders have a rate 25x that of the general public
• Higher rates of co-occurring mental and physical health problems: people with SMI die 10 years earlier than the general population
Opioid Crisis:
• Over 2 million Americans have an OUD—only 1 in 5 receive specialty treatment for illicit drug use
• 63,632 drug overdose deaths in 2016 –44,249 (66%) from opioids
Major Challenges of Our Time
• Establishes an Assistant Secretary for Mental Health and Substance Use to head SAMHSA. Requires the Assistant Secretary to:
– Maintain a system to disseminate research findings and EBPs to service providers to improve prevention and treatment services
– Ensure that grants are subject to performance and outcome evaluations; conduct ongoing oversight of grantees
– Consult with stakeholders to improve community based and other mental health services including for adults with SMI and children with SED
– Collaborate with other departments (VA, DoD, HUD, DOL) to improve care to veterans and service members and support programs to address chronic homelessness
– Work with stakeholders to improve the recruitment and retention of mental health and substance use disorder professionals
21st Century Cures Act Created Assistant Secretary for Mental Health and Substance Use
• Efforts to develop a system to disseminate research findings and EBPs to service providers to improve prevention and treatment services: National Mental Health Substance Use Policy Laboratory
• Focus on the most seriously ill/tackling the biggest issues in behavioral health:– People living with SMI– Opioid Crisis
Refocusing of SAMHSA
• Will promote evidence-based practices and service delivery models through evaluating models that would benefit from further development and through expanding, replicating or scaling EBPs across a wider area– SMI: Particularly schizophrenia and schizoaffective
disorder as well as other serious mental illnesses– EBP and service models for substance disorders with
focus on OUD• Establishing EBP online resources• Review of and modification to data collection tools• Closer relationships with NIH
National Mental Health and Substance Use Policy Laboratory
SERIOUS MENTAL ILLNESSCreating a system that works for everyone living with
SMI and SED and their families
• 21st Century Cures Act required establishment of a Public/Federal partnership to review current programs/practices within the federal government and encourage more collaboration between agencies– SAMHSA will lead these efforts over the next 4 years– Collaboration with HUD, DOL, DOE, CMS, DoD/VA, SSA
– Plan to bring Administration for Community Living and Administration for Children and Families into the efforts
– December 2017 Report to Congress with 45 recommendations: Federal collaboration, treatment issues: access/engagement/EBP, justice diversion/services, community recovery services, finance models
Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
• To keep federal government focused on SMI needs
• To provide feedback about ongoing issues; participate in SAMHSA activities related to special topics in mental illness
• To help in urgent issues: working with SAMHSA leadership and staff on approaches to problems, media contacts/communications with the public, implementation/dissemination
Importance of ISMICC
• Address SMI prevention potential• Increase access to treatment:
– Increase treatment capacity– Innovative approaches– Healthcare practitioner education
• Reduce suicide• Training and technical assistance to communities• Justice intervention programs for those with mental health
issues• Enforce parity laws/work with insurers on best approaches
to coverage for SMI/SED
Plan to Address SMI
• 21st Century Cures Act required establishment of a Public/Federal partnership to review current programs/practices within the federal government and encourage more collaboration between agencies– SAMHSA will lead these efforts over the next 4 years– Collaboration with HUD, DOL, DOE, CMS, DoD/VA, SSA
– Plan to bring Administration for Community Living and Administration for Children and Families into the efforts
– December 2017 Report to Congress with 45 recommendations: Federal collaboration, treatment issues: access/engagement/EBP, justice diversion/services, community recovery services, finance models
Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)
SAMHSA funds programs to assist states/communities with provision of mental health care: Block grants to states: MHBG increased by 305.9 million to 1.49 billion for FY 18 10% set aside for SMI: FEP Children’s Mental Health Services: increased by 6 million to 125 million for FY
18 Integrated Care Programs: CCBHCs allocated additional 100 million for FY 18 Assistance in Transition from Homelessness New Assertive Community Treatment: 5 million FY 18 Assisted Outpatient Treatment Suicide Prevention Programs Criminal Adult and Juvenile Justice Programs
New Infant and Childhood MH program (Cures) $5M AWARE increased by $14M in FY 18 to total of $71M; MHFA-type training
programs increased by $5M to total of $20M Healthy Transitions increased by $6M to total of $26M for FY 18 NCTSI increased by $5M to total of $54M for FY 18
SAMHSA Resources Available to Increase Access to Treatment
• Innovative Programs:– Certified Community Behavioral Health Centers
• Integrates mental health, substance use disorder, physical healthcare
• Requires that all aspects of a person’s health be addressed
• Requires 24-hour crisis intervention services
• Community recovery services connections
• Peer supports
• 2-year demonstration and evaluation
• FY 18: increase funding to additional states to help in program implementation
– Support of programs to integrate BH into primary care
Increase Access to Treatment
• National Lifeline
• Grants to communities/tribal entities to prevent youth suicide
• Zero Suicide: training of healthcare providers to:– Ask about suicidality
– Make safety plans with person and family
– Assure that person gets to treatment
– Follow up contact to verify
Reduce Suicide
• Adult and Youth Treatment Court Collaboratives:– Focuses on connecting with individuals early in their involvement
with the criminal justice system
• Early Diversion Grants: – Establishes or expands programs that divert adults with SMI or COD
from CJ system to community-based services prior to arrest
• Assisted Outpatient Treatment: civil commitment to outpatient treatment– Implements and evaluates new AOT programs– identifies evidence-based practices with goal to reduce the
incidence and duration of psychiatric hospitalization, homelessness, incarcerations, and CJ system interactions
Mental Health CJ-Related Grant Programs
• Develop a national network of training and technical assistance to assure that behavioral health professionals are equipped to meet patient needs– Repository of evidence-based practices on which to base program
services: NMHSUPL
– Clinical Support System for SMI/Center of Excellence for Psychopharmacology
– Regional networks of local trainers to assist colleagues in their communities
• Increase BH workforce: encourage more psychiatry residency training positions; loan repayment programs for BH professionals
Practitioner Training
• Enforce existing parity laws • Work with insurers to educate about SMI
– What clinical evidence there is for treatment approaches
– Encourage insurers to require use of evidence-based models of care inclusive of both medication and psychosocial services
– Encourage insurers to manage spectrum of needs of those living with SMI to assure psychiatric care, physical healthcare, and recovery services in community (e.g. peer support, case management, housing, education and employment)
– Encourage payments for behavioral health services that are equivalent to those for medical services
Financing Care and Treatment of SMI
• FY 2019 PROPOSED PRESIDENT'S BUDGET– MHBG is restored to $562M
– Healthy Transitions restored to $20M
– ACT increased from $5 to $15M
– MH CJ increased from $4 to $14M
Mental Health Services Budget
Opioid Crisis
• 2.1 million Americans with Opioid Use Disorder (OUD)
• Only 20% with OUD received specialty addiction treatment and only 37% of those received MAT
• Over 63,632 drug overdose deaths in 2016 of which 42,249 –66% from opioids
HeaderMILLIONS CONTINUE TO MISUSE RX PAIN RELIEVERS WHILE HEROIN USE CLIMBED THEN STABILIZED
11.8 MILLION PEOPLE WITH OPIOID MISUSE (4.4% OF TOTAL POPULATION)
6.9 MILLION Rx Hydrocodone
3.9 MILLION Rx Oxycodone
228,000Rx Fentanyl
11.5 MILLIONRx Pain Reliever Misusers(97.4% of opioid misusers)
948,000Heroin Users
(8% of opioid misusers)
641,000Rx Pain Reliever Misusers
& Heroin Users(5.4% of opioid misusers)
404,000
828,000
2002 2015 2016
HEROIN USE – PAST YEAR948,000
200K
400K
600K
800K
1M
0
PAST YEAR, 2016, 12+
0.3%
0.2%
0.4%
Heroin Deaths: 2002: 2,013 (est)2015: 13,1012016: 15,469
1.4 fold increase in heroin users6.7 fold increase in heroin deaths
Deaths in 2006
Estimated age-adjusted death rates for drug overdose
Presenter
Presentation Notes
This is how the country looked 12 years ago in terms of overdose deaths. This is a heat map of county estimates, with red being hard hit areas. ___ More Info: Age-adjusted death rates for drug poisonings (or overdoses) per 100,000 population by county for 2006. Source: https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/ Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files The years 2006 and 2016 were selected to show a decade’s worth of growth in overdose deaths and because 2016 is the most recent, publically available data.
Deaths in 2016
Estimated age-adjusted death rates for drug overdose
Presenter
Presentation Notes
This is the same map 10 years later – the 2016 deaths from overdoses. This shows in stark terms the steep rise in deaths, and the regional component. ____ More Info Age-adjusted death rates for drug poisonings (or overdoses) per 100,000 population by county for 2016. Source: https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/ Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files The years 2006 and 2016 were selected to show a decade’s worth of growth in overdose deaths and because 2016 is the most recent, publically available data.
Synthetic Opioid Deaths Closely Linked to Illicit Fentanyl Supply
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
2010 2011 2012 2013 2014 2015 2016
Synthetic Opioids Overdose Deaths
Fentanyl Reports DEA NFLIS
Known or suspected exposure to fentanyl in past year (n = 121)Behavior or experience APR 95% CI pRegular heroin use 4.07 1.24–13.3 0.020
Source: Carroll et al, Int. J. Drug Policy, 2017 and CDC Epi-Aid 2015-2016 OH and MA
The crisis in context
Drug overdose death rates from 1968-2016
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25Dr
ug o
verd
ose
deat
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00,0
00 p
opul
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ge-a
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Heroin
Cocaine
Opioids
Presenter
Presentation Notes
This is another way to visualize the dramatic increase in overdose deaths, particularly in the context of other drug wars. Note how the Heroin epidemic looked in the 1970s. Then, it was Cocaine in the 1980s-1990s. In the 2000s, opioids have taken the lead in the number of deaths--- DWARFING THE OTHERS IN SHEER MAGNITUDE.
Treacherouspotency
Lethal doses of heroin, fentanyl, and carfentanyl[ LEFT TO RIGHT ]
Presenter
Presentation Notes
Why are synthetic opioids like fentanyl and carfentanyl so dangerous? Because the equivalent of what looks like a few grams of salt can kill you. Image source: DEA.GOV https://www.dea.gov/pr/multimedia-library/image-gallery/images_fentanyl.shtml ___ This slide shows how much heroin, fentanyl, and carfentanyl it takes to die from an overdose. Q. What is fentanyl? A. Fentanyl is a synthetic opioid. Fentanyl is a very powerful anesthetic (30-50 times more potent than heroin and 50-100 times more potent than morphine) most often used with patients who are already taking other opioids to relieve chronic or breakthrough pain (such as the pain caused by cancer). Q. What are fentanyl-related substances?�A. Because fentanyl is synthesized, chemists can create a wide range of similar synthetic opioids ranging in potency. Some of the more commonly abused fentanyl-related substances or fentanyl analogs according to the National Forensic Laboratory Information System (NFLIS) are carfentanil (approximately 100 times more potent than fentanyl) acetyl fentanyl, furanyl fentanyl and 3-methylfentanil. Q. Why is fentanyl dangerous? A. In its purest form, fentanyl is a white powder or in grains similar in size to grains of salt. It only takes a very small amount of fentanyl to cause a severe or potentially deadly reaction. As little as two milligrams is a lethal dosage in most people. Consequently, not only are users exposed to danger, but also others who might encounter fentanyl such as first responders and law enforcement officials. Q. What are the effects of fentanyl exposure? �A. The effects of fentanyl exposure resemble those of heroin and include euphoria, drowsiness, nausea, confusion and sedation. With repeated exposure comes tolerance, addiction, respiratory depression and arrest, unconsciousness, coma, and death. Q. What is fentanyl’s legal and medical status? A. Fentanyl is approved by the Food and Drug Administration for limited use as an analgesic (pain relief) and anesthetic, it is often sold illicitly. Fentanyl is a Schedule II narcotic under the United States Controlled Substances Act.
Nonmedical Use of Prescription Opioids Significant Risk Factor for Heroin Use
3 out of 4 people who used heroin in the past year misused prescription opioids first
7 out of 10 people who used heroin in the past year also misused prescription opioids in the past year
Source: Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. (2013). Slide credit – Grant Baldwin, CDC
2016: 2.1 million with opioid use disorder
What is Needed at the Federal Level?
HHS FIVE-POINT OPIOID STRATEGYStrengthening public health surveillance
Advancing the practice of pain management
Improving access to treatment and recovery services
Targeting availability and distribution of overdose-reversing drugs
Supporting cutting-edge research
1
2
3
4
5
Completestrategy
HHS Five-point strategy to combat the opioids crisis
Presenter
Presentation Notes
The opioid epidemic is one of the Department’s top priorities and addressing it is a key part of encouraging healthier people, stronger communities, and a safer nation. In April, under President Trump, HHS launched a new 5-point Opioid Strategy: Improving access to prevention, treatment, and recovery support services Treatment works and recovery is possible for everyone. HHS has issued over $700 million dollars in targeted grants to support access to treatment, prevention, and recovery. Strengthening timely public health data and reporting We have to understand the epidemic in order to stop it. HHS is improving our understanding of the crisis by supporting more timely, specific public health data and reporting. Advancing the practice of pain management We need to do a better job of treating the real problem of pain in America. HHS wants to ensure everything we do—payments, prescribing guidelines, and more—promotes healthy, evidence-based methods of pain management. Targeting availability and distribution of overdose-reversing drugs Every life matters. HHS is committed to making lifesaving overdose-reversing drugs, such as naloxone, more accessible and affordable. Supporting cutting-edge research We need more tools to help us win this fight. HHS is supporting cutting edge research on pain and addiction.
Plan to Address the Opioid Crisis: Getting it Right1. Assessing the Need
What do Americans know and understand about risks of prescription pain medications and heroin?What is the current state of service delivery for OUD?
2. Establishing effective practicePrevention educationFirst responder trainingNaloxoneMAT/psychosocial supports/community recovery supports
3. WorkforceIs there a trained workforce ready to take on OUD in a variety of medical settings?How do we train the workforce?How do we assure that individuals with OUD are detected and get to the care/services they need?
4. Increasing Prevention/Treatment/Recovery Funding/ResourcesHow much funding is needed to address the epidemic? How should that funding be distributed? How do we determine that money is being spent appropriately and obtaining desired outcomes (metrics/data analysis)
5. ImplementationRapid, efficient service deliveryTimely, safe, and effective interventionsClose observation and modifications in real time
FY2017 Estimated HHS opioid-related funding (in millions) for 2018 & beyond
Workforce Needs
Improve treatment & prevention
efforts
Find alternative
pain medications
Behavioral Health OTHER
Presenter
Presentation Notes
Government-wide, about $4.6 billion twill be spent to combat the opioid crisis. This is a $3 billion (192 percent) increase over FY2017. For HHS ‘s work in Fighting Opioid Abuse: $3.6 billion, an increase of 244% Funds are targeted towards: improving treatment and prevention efforts; finding alternative pain medications; workforce needs, especially in our rural communities; and behavioral health. This is replacing the heat map of spending. In FY17, we estimate that HHS granted over $900 million dollars for opioid-related activities throughout the US. A majority of these funds come from implementing the 21st Century Cures Act - $485 million https://www.cdc.gov/drugoverdose/data/statedeaths.html
30STR Region IX Awards
Arizona $12,171,518California $44,749,771Hawaii $2,000,000Nevada $5,663,328
Plan to Address the Opioid Crisis: FY 18 Increased Resources
Substance Abuse Treatment: $3.18B, an increase of $1.05B from FY17 New $1B Opioid grant program $50M set-aside for tribes 15% set-aside for states hardest hit Includes prevention, treatment, and recovery language
MAT PDOA increased by $28M (total: $84M) PPW increased by $10M (total $29.9M) CJ increased to $89M ($70M for Drug Courts) BCOR (peer specialist training programs) increased by $2M (total: $5M) MFP: addiction psychiatry, addiction medicine, psychology ($1M increase to
total of $4.5M) Reinstatement of Drug Abuse Warning Network (DAWN) at 10M
Plan to Address the Opioid Crisis: President Trump’s Budget Proposal
• STR grants to states: 500 M/yr through Cures FY 17 and 18; President’s budget continues increased funding at 1 B in FY 19
• Public outreach: prevention/education/treatment/recovery services• Overdose Reversal Drug Access Programs: increased from 24 to 48 M in FY 18• President’s budget: increase to 75 M FY 19• MAT-PDOA • Block grants to states • Pregnant/post partum women/NAS: increase from 20 to 40 M in FY 19• CJ programs with MAT; increase from 60 to 80 M in FY 19• Recovery Coaches • HIPAA/42 CFR: Family inclusion in medical emergencies: overdose• FY 19 DFC proposed as new program to SAMHSA at 100 M• New Injection Drug/HIV Program at $150M• Consistent with President’s Opioid Commission Report recommendations
Healthcare Practitioner Training/Preparation
STR Technical Assistance/Training Grant: individualized training according to state needs by local teams of addiction treatment providers
DATA waiver training in pre-graduate settings: medical, NP, PA programs
Encourage national certification program for peer workforce
Establish training on recognition and treatment of substance misuse/abuse/use disorders in healthcare professional training programs
Integration of BH including OUD treatment into primary care/FQHCs
Use of telehealth/HIT: alternative training method/increased access to care
What Does Evidence-Based Treatment Look Like?
Combination of FDA-approved medication (Medication Assisted Treatment (MAT)): for as long as the person benefits from the care
• Naltrexone: once a month injectable medication, blocks effects of opioids• Methadone: long acting, once-daily, opioid from specially licensed programs• Buprenorphine/naloxone: long acting, once daily/once monthly, opioid from
doctor’s offices; available by prescriptionMedical Withdrawal (“Detoxification”)
• > 80% relapse rate in the year following treatment• High risk for overdose and death when relapse occurs• Should not be a stand alone treatment
Addressing Safety: Naloxone dispensing
What Does Evidence-Based Treatment Look Like?• Psychosocial therapies/treatment components
Counseling: Coping skills/relapse preventionPDMP useToxicology screening
• Community Recovery Supports: Rebuilding One’s LifeSocial supports to bring the person back into the healthy community: family, friends, peers, faith-based supportsRecovery HousingEmployment/Vocational training/educationAssistance with needs that can impact treatment: transportation, child care
• Patient-centered evaluation of treatment setting need: outpatient vs. inpatient/residentialMajority can be treated in outpatient settingsCo-occurring disorders (need alcohol, benzodiazepine withdrawal)Co-occurring serious mental or medical illness needing treatmentHomeless
Medication Assisted Treatment: Effective and the Standard of Care
MAT treatment of Opioid Use Disorders in criminal justice populationMethadoneBuprenorphine/naloxoneInjectable naltrexone
Medication treatment while in DOC; referral to ongoing care for OUD on releaseComparison of opioid overdose deaths first 6 months of 2016 vs. 2017:61% reduction in opioid-associated overdose deaths upon release from incarcerationOverall 12% reduction in opioid overdose deaths in Rhode Island (2016-2017)Importance of MAT and warm handoff to outpatient providers
Green TC, et al. JAMA Psychiatry, 2018
Medication Assisted Treatment Makes Recovery Possible
Use of medication to treat opioid use disorder is not continuing addiction, not ‘substituting one drug for another’
Opioid medications used to treat opioid addiction: Block withdrawal All three medications help to reduce opioid craving
Use once monthly to once daily: eliminates compulsive use of drug multiple times a day Development of tolerance Numerous studies show that relapse occurs at high rates when medication is stopped Discontinuation needs to be done carefully and in collaboration with healthcare providers Treatment helps people to re-establish healthy lifestyles, work on rebuilding relationships,
obtain employment, care for their families Opioid use disorder is a chronic illness; medication may be needed chronically
Signs of Progress: Opioid prescribing declining since 2011
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Es
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ber o
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scrip
tions
Opioid Prescriptions Moprhine Milligram Equivalents
Source: IQVIA National Prescription Audit, data extracted 2016-2018
Signs of Progress: Receipt of MAT from treatment facilities
Methadone
Source: SAMHSA NSSATS
Signs of Progress: Consistent increases in number of patients receiving buprenorphine and naltrexone from retail pharmacies
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Patie
nts
Naltrexone Buprenorphine
Source: IQVIA National Prescription Audit, data extracted 2016-2017
Signs of Progress: Dramatic increases in naloxone dispensing from U.S. pharmacies
0
20,000
40,000
60,000
80,000
100,000
120,000
State laws changing on Naloxone at rapid pace
Source: IQVIA National Prescription Audit, data extracted 2016-2018
Signs of Progress
• Youth prescription opioid misuse declining over past decade; heroin use stable among youth
• Prescription opioid misuse initiation declining
• Plateauing of overdose deaths involving commonly prescribed opioids
• Some states seeing a leveling off of overdose deaths
Presenter
Presentation Notes
Here are some hopeful signs Fewer youth misusing opioids Overall, prescription opioid misuse initiative declining Leveling off of deaths from prescribed opioids (but this gain is more than negated by huge uptick in synthetic opioid deaths)
Conclusions
• The opioid epidemic continues to evolve• Urgent need to prepare workforce rapidly and deliver evidence-
based prevention, treatment and recovery services• Substantial efforts underway to combat the opioid epidemic, but
gaps in the evidence base remain• Some emerging signs of progress• Work continues to aggressively address the epidemic
Evidence-Based Practices Resource Center• New SAMHSA website launching today
• Aims to provide communities, clinicians, policy-makers and others in the field with the information and tools they need to incorporate evidence-based practices into their communities or clinical settings
• Contains a collection of scientifically-based resources for a broad range of audiences, including Treatment Improvement Protocols, toolkits, resource guides, clinical practice guidelines, and other science-based resources
www.samhsa.gov/ebp-resource-center
Behavioral Health Treatment Services Locatorfindtreatment.samhsa.gov
