Update on Current Opiate Epidemic

June 6, 2019 Beth Johnson MD

Inpatient Psychiatric Medical Director

Medication Assisted Treatment Medical Director

Franciscan Health Indianapolis

John 1:5

5 The light shines in the

darkness, and the darkness

has not overcome it.

Information wanted / Questions / Concerns from Med-Surg staff polled on the Med-Surg Workshop

topic: The Response of Staff to the Opioid Crisis in Healthcare

1 Why an Opioid Crisis? Let us talk about the addict and heroin, meth, crack etc.

2 Why such an increase in drug overdosing?

3 How to care when you have had enough (conflict, demands, entitlement etc.)

4 Why addict lives matter

5 Discharged yet again with no services available, no help left all alone to use again

6 Let’s talk about Methadone or Suboxone Clinics – who, what and why

7 Behavior health is here – services aren’t

8 Addiction is real – Narcan is too. (Why do we continue to give Narcan repeatedly – let’s talk about Ethics, why

aren’t addicts given Narcan arrested?)

9 Who cares? Not everyone is born to addiction, it is not as if someone woke up and said, hey today I want to be an

addict: so who is at risk for addiction, why are they at risk for addiction, what are the signs (red flags) before

someone becomes and addict?

10 Why do I have to care for these addicts?

11 Where are these drugs coming from? What about this Fentanyl education and why are people knowledgeable

about this drug and lacing drugs with it?

12 How can I help? – Should I help? – Where do I go to find them help?

13 How do we teach staff? What do we need to do?

14 Addiction statistics (staggering) and what the future holds

15 This population is challenging – manipulative, demanding, chronic, sick, and unsafe/unstable

What is an opioid/opiate? • Opioids are a class of drugs that include the illegal drug heroin,

synthetic opioids such as fentanyl, and pain relievers available legally

by prescription, such as oxycodone (OxyContin®), hydrocodone

(Vicodin®), codeine, morphine, and many others.

• These drugs are chemically related

• interact with opioid receptors on nerve cells in the body and brain.

CDC Information Through 2015

Opiate Related Deaths Through 2015

• From 2000 to 2015 more than half a million people died from drug

overdoses

• From1999-2015, the number of overdose deaths involving opioids

(including prescription opioids and heroin) quadrupled

• The majority of drug overdose deaths (more than six out of ten)

involve an opioid

• Overdoses now leading cause of

death of Americans under 50

Drug overdoses killed

more Americans last

year than the entire

Vietnam War

Among those who died from

prescription opioid overdose between 1999 and 2014:

• Overdose rates were highest among people aged 25 to 54 years.

• Overdose rates were higher among non-Hispanic whites and

American Indian or Alaskan Natives, compared to non-Hispanic blacks

and Hispanics.

• Men were more likely to die from overdose, but the mortality gap

between men and women is closing

In 2015, more than 15,000 people died

from overdoses involving prescription opioids

• Drug overdose deaths can be hard to categorize

• In approximately 1 in 5 drug overdose deaths, no specific drug is listed on the death certificate.

• In many deaths, multiple drugs are present, and it is difficult to identify which drug or drugs caused the death (for example, heroin or a prescription opioid, when both are present).

Opioid Related Overdose Mortality Trend

2000-2015

PROVISIONAL COUNTS OF DRUG

OVERDOSE DEATHS, as of 8/6/2017 -- CDC

2016: 165 Americans Died

Every Day From an Opioid Overdose

2015

Relative Opioid Potency

OPIOD ANALGESIC Strength Dose Bioavailability X (relative) (10 morphine)

• Morphine oral 1 10 mg ~25%

• Hydrocodone 1 10 mg 80%

• Oxycodone 1.5 6.67 mg 87%

• Morphine IV/IM 3 3.33 mg 100%

• Methadone (acute) 3–4 2.5–3.33 mg 40–90%

• Methadone (chronic) 2.5–5 3.33 mg 40–90%

• Hydromorphone 4 1.5 mg SC/IV/IM IV/IM:100%

7.5 mg PO PO:30-35%

• Heroin IV/IM(Diamorphine) 4–5 2–2.5 mg 100%

• Buprenorphine 40 0.4 mg 35–40% (SL)

• Fentanyl 50–100 0.1 mg (100 µg) IM/IV 33% (SL); 92% (TD)

• Carfentanil 10,000–100,000 0.1–1.0 µg

Graphic representation of Increasing Rates Neonatal Abstinence (NAS)

through 2014

Conclusions

• Our hospital, community, state, region, and country are in the grips of a severe, accelerating, opioid epidemic.

• We currently only measure deaths related to overdose, and we don’t have data on 2016 yet, only estimates.

• We are not measuring other deaths related to use, or the broader impact of the opioid crisis medically.

• We do not have good scientific data on 2017.

Conclusions

We are seeing the “tip of the iceberg” here in

the acute hospitalization setting. • Our inpatients have such severe illnesses that they have no choice

to present to the ED despite the consequences (withdrawal,

stigma, fear, judgement). They are out of options.

• Despite this, many of our patients try to leave AMA or elope despite

their situation demanding immediate hospitalization: Endocarditis,

Sepsis, Abcesses, Impending Delivery of their Baby, Delivery of their

Baby with Neonatal Abstinence Syndrome.

• We do not know the community risk for the vast majority, unknown

addict: Ongoing fetal exposure, OD, Hepatitis C, HIV,

psychosocial, criminal, and public health risk.

Conclusions

• Most of our patients do not plan to stop using/are not ready to get sober.

• All of our patients want to be out of withdrawal.

• Contraband is very common with these patients: staff,

patients, visitors are at risk.

o Staff needs to know symptoms of withdrawal, acute

intoxication, and overdose for our inpatients.

• It is common that we are not giving adequate opiate

dosing compared to what the physiologic dependence

requires.

Conclusions

• Methadone and Buprenorphine (suboxone) seem to have the best outcomes to help calm withdrawal, and encourage patients staying for the course of treatment.

• There are ethical challenges with treating inpatients with MAT, when there are not resources in the community to continue the treatment.

• There are ethical challenges treating these patients medically when they continue to use, and re-admit despite valve replacements, multi-week hospital stays, challenging, risky, and/or illegal behaviors in the hospital.

Urgent Considerations • Terrible patient outcomes

• Staff safety concerns

• Impact on staff compassion fatigue and burnout

• We need leverage with these patients: legal or via civil commitment

SEVERE FINANCIAL RISK TO OUR HOSPITAL, COMMUNITY, AND STATE

Recommendations

• Reconsider approach to INSPECT and UDS for inpatients weighing

reality of epidemic vs. patient right to privacy and civil liberty

• Consider policy, procedures and possible co-horting of patients

with active SUD: prevent contraband, control flow of visitors and

enforce safe behavioral standards/requirements

• Encourage/incentivize physicians to get their buprenorphine

prescribing waiver for inpatient care

• Consider treatment contracts for patients needing medical care o Create inpatient substance abuse assessment/treatment service to start drug treatment while in

the hospital: telehealth with CDIOP/continuity with outpatient MAT

o Outpatient MAT

Models of Treatment on the National Front

National Opioid Crisis Management Congress

February 22-23, 2018

Orlando, Florida

US Dept of Health & Human Services

HHS Specific Strategies

• Strengthen public health surveillance

• Advance the practice of pain management

• Improve access to treatment and recovery services

• Target availability and distribution of overdose-

reversing drugs (naloxone, Narcan)

• Support cutting-edge research

SAMHSA’s Specific Strategic Initiatives

• Prevention of Substance Abuse and Mental Illness

• Trauma and Justice

• Recovery Support

• Health Care and Health Systems Integration

• Health Information Technology

• Workforce Development

WVU Medicine - Philosophy of MAT • Containment, not cure

• Goal: Decrease morbidity and mortality

• Multi-phasic

o Detox

o Recovery

• Multi-disciplinary

o Psychiatrist, PCP, etc.

o Therapist, clergy, etc.

o PT, dietician, trainer, etc.

• Multi-dimensional

o Bio-psycho-social-spiritual

• Collaborate with the patient

UPMC Health Plan’s Hub & Spoke Model

• Regional Hubs that provide coordination and

care to the patients in their community

• Continuum of care rather than disconnected care

• Assertive rather than passive engagement by the patient

• Triaged to the appropriate level of care rather than one level of care for all

• Stepped care based on their response to treatment rather than minimal counseling for all

Current Model: Either or, but not both

• Access to medications (MAT)

• Methadone Treatment

• Primary Care

• XR-naltrexone at discharge

from rehab

• Access to abstinence-based

treatments

• Buprenorphine tx

• D & A treatment

• OP care & case management

Kentucky Cabinet for HHS – Integrated Treatment for

Pregnant and Parenting Women with Opioid Use Disorder

• Maternal Home Care Model

oEarly engagement in pre-natal care

oAddiction treatment & counseling

oMAT

oCare management

oPostpartum & interconception care

oHousing & recovery supports

Key Personnel

• Nurse Navigator/Care Coordinator

• Targeted Case Manager

• Peer Support Specialist

University of Maryland/Baltimore Washington Medical Center

Overdose Survivor Outreach Service

Goals • Identify people in an ED setting after an overdose or other opioid-

related issue

• Link them to MAT or other Substance Use Disorder treatment

Program Services • Substance Use Disorder screening and referral

• Peer Support services

New Staff Member • Peer Support Specialist

Behavioral Health Services

• Current Services o Emergency Department Crisis Consults

o Hospital Inpatient Consult/Liaison

o Outpatient Behavioral Health Services (Mental Health and Substance Use Disorders) • 610 E. Southport Road

• 1001 Hadley Road

o Integrated Care Services

• IIMC • Kendrick Family Medicine

• Neuropsychology with Neuroscience/Rehab Services

Behavioral Health Services

• Future Services

o Move Southport Rd. location to 5230 E. Stop 11 Road

o Franciscan Psychiatric Specialists, Outpatient Behavioral

Health, and a Substance Use Disorder Treatment Center,

including Medication Assisted Treatment

o Add Addictions Peer Recovery Coaches to the team

o More collaborative care with Women and Children's Service

and other specialty services.

References

• 2018 National Opioid Crisis Management Congress, February 2018

o Dr. James H. Berry, Western Virginia University

o Anthony B. Campbell, RPH, DO, FACP, CDR, USPHS, U.S. Dept. of

Health & Human Services, SAMHSA

o David Loveland, PhD, University of Pittsburgh Medical Center Health

Plan

o Kris Shera, Kentucky Cabinet for Health and Family Services

o Kurt Haspert, MS, CRNP, APN-BC, University of Maryland, Baltimore

Washington Medical Center