Andrew J Barnes & Rose S Bono Health Behavior and Policy Virginia Commonwealth University Virginia’s Opioid Epidemic and Health Policy

Acknowledgements 2 Virginia Department of Medical Assistance Services Virginia Association of Health Plans Virginia Health Information VCU Office of Health Innovation

Part 1: The pill bottles, the needles, and the damage done….. 3

4 Common prescription opioid painkillers include hydrocodone, which is generic for Vicodin, and oxycodone, which is generic for OxyContin.

5 Opioid Overdose Death Rates are on the Rise in the US CDC. MMWR Updated with 2009 mortality and 2010 treatment admission data.

6 CDC estimates 20% of patients visiting a doctor’s office for non-cancer pain symptom management or pain-related diagnoses receive an opioid prescription

Fatal Drug Overdoses in Virginia Deaths from prescription opioid and heroin overdoses increased 38 percent in the Virginia between 2012 and 2014 alone. Nearly 80% of the over 1,000 fatal drug overdoses in 2014 involved prescription opioids or heroin.

Disproportionate Impact on Rural Communities

9 The Virginia Picture In 2013, more Virginians died from drug overdose than car accidents and were three times more likely to die from overdose compared to homicide. Virginia OCME’s Top 3 Methods of Death by Number and Year of Death

Opioids Use and Misuse in Virginia’s Medicaid Population 10 At least 40,000 adults in Virginia’s Medicaid program have a substance abuse disorder, and more than 50 percent of Medicaid enrollees with a serious mental illness also have a substance use disorder. More than 1,300 children were born in Virginia between 2011 and 2014 with neonatal abstinence symptoms because of maternal substance abuse. Medicaid is the largest payer for births in Virginia Virginia’s Medicaid program spent $26 million on opioid use and misuse in 2013 $10 million of this spending occurring in southwest Virginia.

11 Impact of Substance Use Disorders (SUD) on Virginia’s Families Limited Coverage: Non-pregnant adults cannot receive residential treatment; instead receive more expensive inpatient detox. Pregnant women lose substance abuse treatment coverage 60 days after delivery. Fragmented System: SUD treatment services are separated from mental and physical health services Incomplete Care Continuum Lack of Providers: Rates for SUD treatment have not been increased since 2007 and don’t match the cost of providing care. This severely limits number of providers willing to provide services to Medicaid members. Providers also struggle to understand who to bill for services. Consumers do not know where to seek services. Limited Access to Services Current SUD Delivery System is Impacting VA Families: Neglect due to Substance Use Disorders was the #2 reason Virginia children entered foster care in 2013, but over half of mothers with children in foster care have waited more than 12 months for court mandated SUD services (according to the 2013 Title IV B report).

12 Conservative estimates indicate untreated substance abuse costs Virginia state and local governments more than $600 million annually in public safety and health care services alone.

Part 2: The health policy response… 13

14 Photos courtesy of Craig Zirpolo

15 Safe Reporting of Overdoses: state law provides limited affirmative defense to prosecution for drug and paraphernalia possession if the charge is obtained when someone calls 911 to report an overdose Public education initiatives: Office of the Attorney General of Virginia presented “Heroin: The Hardest Hit” documentary, with public screenings Virginia pharmacies working to implement standing orders to dispense naloxone without a prescription Some law enforcement now carrying naloxone (ex. Henrico County Sheriff’s Office)

16 A Commonwealth of Virginia Partnership January Transforming Virginia’s Medicaid Delivery System for Individuals with Substance Use Disorders (SUD)

17 Actualizing Change and Progress for Virginia Families Governor’s Task Force on Prescription Drug and Heroin Abuse: Recommendations Focus on population health and community initiatives. Examine and enhance Medicaid reimbursement for substance abuse treatment services. Ensure health plans are complying with the Mental Health Parity and Addiction Equity Act by providing adequate coverage for treatment, including Medication Assisted Treatment (MAT). Explore and expand use of appropriate peer support services, with necessary oversight. Six Proposed SUD Budget Supports for Members in Current Medicaid Program Expand short-term SUD inpatient detox to all Medicaid members; Expand short-term SUD residential treatment to all Medicaid members; Increase rates for existing Medicaid/FAMIS SUD treatment services; Add Peer Support services for individuals with SUD and/or mental health conditions; Require SUD Care Coordinators at Medicaid health plans; Provide Provider Education, Training, and Recruitment Activities.

18 Potential Costs & Savings of SUD Benefit to the Commonwealth  Fiscal Year 2017: $2.6 million in State General Funds  (Benefit would start on January 1, 2017)  Fiscal Year 2018: $8.4 million in State General Funds Potential Savings to the Commonwealth: Every dollar invested in Addiction Treatment generates $7 in cost savings to health care and criminal justice systems* Decreased Medicaid Emergency Department and inpatient costs: Kaiser expansion of outpatient SUD treatment resulted in a 35% decrease in inpatient and 39% decrease in ED costs. Decreased costs to criminal justice system. Average annual cost of SUD treatment is $2,400 vs. average annual prison cost of a drug offender is $55,000. Increased access to treatment may lead to a decrease of incarceration for people with SUD. New revenue from increased employment and productivity: Every $1 invested in SUD treatment is estimated to generate $2.82 in new state tax receipts. * Substance Abuse and Mental Health Services Administration

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Virginia Hospital Emergency Department Opioid Prescribing Guidelines 20 In January 2016, a task force on Prescription Opioid Abuse was established that was charged with finding ways to combat opioid abuse, and developing prescribing recommendations to guide hospital emergency departments (ED). Some of the guidelines released this month include: A dedicated provider outside the ED should provide all opioids to treat any patient’s chronic pain. Prescriptions for opioids from the ED should be written for the shortest duration appropriate Hospitals and EDs should develop processes to screen for substance misuse, brief interventions, referrals Think twice about prescribing opioids to patients without a photo ID. ED providers should not dispense prescriptions for lost controlled substances or if finished prematurely ED providers should consult the PMP before writing opioid prescriptions for acutely painful conditions. ED providers should generally not prescribe long ‐ acting or controlled release opioids (e.g., oxycodone). Hospitals should support physicians’ decisions even if a patient has requested a prescription. Post signs that staff consults the PMP prior to prescribing controlled substances as is required by law

Other state and local responses recently considered 21 Supervised injection facilities (Maryland; Ithaca, NY) Heroin-assisted treatment Law-enforcement assisted diversion Decriminalization of small amounts of drugs (Maryland) Mandated insurance coverage of abuse-deterrent opioid formulations (Kentucky)

Federal Level Responses 22 Senate recently passed Comprehensive Addiction and Recovery Act: Diversion programs (away from criminal justice, toward treatment) Expand medication-assisted treatment (buprenorphine, methadone), particularly in correctional settings Put naloxone in hands of law enforcement (first responders) More funding for federal law enforcement Congress ends ban on federal funding for needle exchange May not prevent overdoses directly, but can link people to treatment

CDC releases opioid prescribing guidelines 23 When to use opioids in chronic pain (not cancer or palliative care) Not first line of therapy – try non-drug pain management or non-opioid drugs Choosing a type, dose, and amount of opioids (ex. do not prescribe extended release/long acting opioids for acute pain) Making a plan with patients for pain management (treatment goals) Addressing risks of opioid use No longer recommending testing for cannabis use in pain management

Obama Administration Actions to Combat Prescription Opioid Abuse and Heroin Epidemic 24 President proposed 1.1 Billion in his budget this year to help every American with an opioid or heroin addiction who wants treatment to get the help they need. Mental Health and Substance Use Parity Task Force Expanding treatment Providers would be allowed to treat up to 200 patients with buprenorphine (previous limit was 100 patients) Medication-assisted treatment Funding for Community Health Center treatment services Evaluating treatments Prescriber education at 60 medical schools (including VCU) Federal funds available for needle exchange, naloxone training and distribution Law enforcement

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