Update on State-Level Strategies to Curb the Opioid Epidemic Nick Szubiak, MSW, LCSW Integrated Health Consultant

The National Council for Behavioral Health HealthCare's Behavioral Health support to address the Opioid Epidemic The National Council is … impacting state healthcare system to improve outcomes and save lives. The National Council is… helping change how people experience care, the way providers deliver care, simultaneously reducing the cost. The National Council is… changing the way healthcare and communities view, conceptualize and treat substance use disorders.

Objectives for today Opioid Epidemic Overview State Strategies Medication Assisted Treatment Overview Substance Use Disorder Treatment What is the National Council doing now Where are we going

Rx opioids 4x as many deaths In 2013 as 1999.

Accidental Death Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014 Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 201 CDC

Opioid increase Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600%.2 Our rate of opioid prescribing his increased from an average of 96 morphine mg equivalents per person in 1997 to over 700 mg per person in 2007. That is an increase of greater than 600%2. That is enough opioids for every man, woman, and child in United States to take Vicodin around-the-clock for over one month.

225% Percent Increase in Neonatal Abstinence Syndrome live births from 2000 to 2009 Schumacher and Benneyworth, 2012

2002 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

2007 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

2014 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

Rise in Rx overdose deaths since 2000 and recent increase in heroin & fentanyl deaths SOURCE: National Vital Statistics System Mortality File.

Quarter billion opioid prescriptions in 2012

US prescription opioid deaths quadrupled between 1999 - 2013 Why Focus on Medicaid? US prescription opioid deaths quadrupled between 1999 - 2013 CDC identified addiction to prescription opioids as the strongest risk factor for heroin addiction Medicaid enrollees are prescribed prescription opioids at twice the rate of non-Medicaid patients Medicaid beneficiaries are at three-to-six times the risk of overdose involving prescription opioids. North Carolina found that while the Medicaid population represented approximately 20 percent of the overall state population, it accounted for one-third of drug overdose deaths, the majority of which were caused by prescription opioids. Washington state found that 45% of people who died from prescription opioid overdoses were Medicaid enrollees. Some states found that Medicaid enrollees made up 45% of all prescription overdose deaths between 2004-2007 Medicaid enrollees are at higher risk of prescription opioid overdose than non-Medicaid patients

The National Council Opioid Epidemic Impact Initiative MAT Learning Community Project ECHO Learning Community SBIRT Hilton Projects CIHS: MAT, SBIRT, Integrated SUD TX

Open Society Foundations Centers for Disease Control and Prevention Medicaid National Meeting on Prescription Drug Abuse and Overdose in Arlington, VA on February 1st and 2nd 21 states: Medicaid Directors and representatives from State Medicaid Agencies, State Substance Use Agencies, and State Associations for Specialty Behavioral Health Providers Funders: Open Society Foundations Centers for Disease Control and Prevention Pew Charitable Trusts Partners: National Association of Medicaid Directors American Academy of Addiction Psychiatry Association for Community Affiliated Plans American Society of Addiction Medicine National Association of Community Health Centers

21 States Arizona Arkansas Colorado Delaware Florida Indiana Maine Maryland Michigan Mississippi Missouri Montana Nebraska New Jersey Ohio Oklahoma Oregon Rhode Island South Carolina Texas West Virginia

Meeting Agenda An overview of NAMD’s “State Medicaid Interventions for Preventing Prescription Drug Abuse and Overdose,” Prescription drug abuse among Medicaid beneficiaries State approaches to improving opioid prescribing An update on the Medicaid Prescription Drug Program from the Centers for Medicare and Medicaid Services Methadone and treatment of chronic pain Efforts to address barriers to MAT among Medicaid programs.

What are states doing? Provider Education Prescriber Practices specific to Opiate RX, Provider Monitoring: Prevention practices, misuse, overuse, Education on MME (morphine milligram equivalent) alternatives to opiates Substance Use Disorder Services for Opiates: SBIRT, Naloxone, MAT (Buprenorphine), Detox services, Treatment services, Prevention Integration and coordination/collaboration with Medicaid with state agencies and resources Medicaid Infrastructure/Funding/Expansion: Increase Medicaid resources for treatment Data Management and Utilization: Identify Hotspots, PMP (Prescription Monitoring Program), ID outlier Prescribers

Action Plans Delaware Improved collaboration with the managed care organizations in their state and providers  Bringing the different groups together at one table to address the epidemic as a unifying focus and resulted in overall improved processes  Maine Provider education requirements and has worked with the American Academy of Addiction Psychiatry’s  PCSS-O program Montana Process of medical, substance use treatment, public health departments and the Attorney General office implementing delegated access for PDMP to help improve utilization of this tool Mississippi Methadone – removed from preferred drug list MAT meds now an available medication and worked to remove authorization barriers Oklahoma identified at the in person meeting that early identification and screening was an important action item for their state  Funding and support for SBIRT codes.

Why was this…… 1. We talked an important talk….. 2. Provided support for mapping what way to walk: Structure of the convening: presentations, learn from each other, TIME to talk, learn, create and develop

We support can opening and worm collection …….different? 3. Support and Assistance for Action Planning: Why isn’t something happening? Why aren’t people working together? Accountability We support can opening and worm collection

Cross Agency Collaboration Division of Behavioral Health & Recovery Department of Corrections Labor & Industry Department of Health Health Care Authority Collaborative Efforts AMDG Guidelines Chronic Pain Rules Prescription Monitoring Program Policy Statewide Plan Medication Assisted Treatment Cross-Agency Collaboration Projects Shouldn’t “Medicaid” be at the top of the circle?

OEII OUTCOMES 100% of the attendees reported a better understanding of State Approaches to Improving Opioid Prescribing 71% reported a better understanding of Medicaid Prescription Drug Programs 93% reported a better understanding of Methadone and Pain prescribing.

Effectiveness of pain meds (from Cochrane reviews) It is also important to recognize that opioids are not very good pain relievers. A number of Cochran reviews have looked at postoperative pain relief. They measure adequate pain relief as a 50% reduction in pain.   They found that the combination of 10 mg of oxycodone +1000 mg of acetaminophen (roughly the equivalent to 5 mg Percocet pills) gave adequate pain relief to about 37% of the people who took it17. 200 mg of ibuprofen alone resulted also in 37% with adequate pain relief18. Basically, the equivalent of 2 Percocet pills. Note that increasing to 400 mg of ibuprofen only gives adequate pain relief to an additional 3% of people. 600 or 800 mg of ibuprofen does not do much better but does significantly increase the risk of side-effects. Oxycodone alone is not a very good pain reliever. 15 mg of oxycodone gave adequate pain relief to only 21% of people17. Taking 2 Tylenol #3 pills only gets adequate relief to 24% of people19. However when we combine the over-the-counter dose of ibuprofen with an over-the-counter dose of acetaminophen taken together– a whopping 62% of people get adequate pain relief20. What’s more, studies have shown that over-the-counter doses of ibuprofen and over-the-counter doses of acetaminophen have side effect profiles similar to placebo when taken as directed5.

Comments/Thoughts/Inquiries Opioid Epidemic Impact Initiative

Lemonade Our Work is about changing culture, treatment approaches, mindsets, systems and most importantly improving outcomes and SAVING LIVES

MAT Coverage: A Snapshot MAT is evidence-based treatment for a chronic disease Medications for opioid dependence Buprenorphine Methadone Naltrexone/Vivitrol Medications for Alcohol and Nicotine NRTs Antabuse Very low utilization of extended-release injectable naltrexone Research is limited regarding the impact of prior authorization (PA) on medications for alcohol and opioid use disorders. However, research on the effect of PA on antipsychotics to treat schizophrenia or bipolar disorder shows that PA policies lead to higher rates of treatment discontinuation and hospitalization. Formulary restrictions on atypical psychotics have also been associated with higher total medical expenditures among Medicaid patients with schizophrenia and bipolar disorder.

Addiction: A Chronic Relapsing Disorder “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.” - ASAM Bio-Behavioral Disorder

Addiction: A Chronic Relapsing Disorder Addiction is 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. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM)

Bio-Behavioral We now understand that while substance use begins with a choice, addiction is a complex disease which impairs brain functioning.   This knowledge is challenging how we think about and treat addiction. It also challenges those of us who dedicated our careers to substance use treatment to find out we were practicing with absolute dedication using inadequate tools. This is not an easy dynamic to manage personally and professionally.

MAT – The Bridge “the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.” SAMHSA

Background: MAT for OUDs MAT is the gold standard for OUD treatment: Reduces drug use Protects against overdoses Prevents injection behaviors Reduces criminal behavior

Evidence Base A 2011 study in The American Journal of Managed Care found that among individuals with alcohol dependence, those receiving MAT had fewer inpatient admissions than those not receiving MAT; and health care costs were 30% less for the group receiving MAT.2 A 2011 study in The American Journal of Managed Care found that among adults with opioid dependence, MAT was associated with fewer inpatient admissions and 29% overall lower health care costs than patients who did not receive medications.3 A 2012 Drug Alcohol Dependence study found that among adults with opioid dependence receiving MAT, after 18 months, 77% continued their MAT. Those who continued with MAT were more likely to be abstinent from drugs, to be participating in a 12-step recovery program, and to be employed.4 A 2010 New England Journal of Medicine study found that among drug-addicted pregnant women, hospital stays were shorter for women receiving MAT, than those not receiving MAT (10.0 days vs. 17.5 days).5 A 2011 study from The American Journal on Addictions found that opioid addicted patients who were compliant with their MAT were ten times more likely not to relapse than patients who were not compliant with MAT Open Minds, 2015

Great! But we don’t like using it…. 11/8/2018

MAT Learning Community

MAT Learning Community Technical Assiatnce for prescribers Integration Evidenced Based Practices Culture Change Discrimination Screening Data – Outcomes

PCSS MAT Webinar Series Webinar 1 (September 30th, 2015 at 1 PM ET): Opioid Use Disorders (OUDs) 101 & Medication Assisted Treatment Participants will acquire foundational knowledge about MAT, including an overview of MAT approaches for opioid addiction (safety and efficacy and related myths). Webinar 2 (October 6, 2015 at 1 PM ET): Making the Case: How MAT Improves Mental Health Care for those with OUDs Participants will have the opportunity to learn about MAT’s contribution to improved mental health care and outcomes for individuals with mental illnesses and opioid use disorders, and learn about successful modalities for mental health and MAT coordination and integration. Webinar 3 (November 4th or 17th, 2015): MAT Roundtable: Lessons Learned from 3 CBHOs Implementing MAT for Opioid Dependence  Participants will gain knowledge about successful and replicable models of mental health and MAT integration, which may include the full adoption of MAT in CBHOs or strong and smooth bi-directional relationships (strong referral networks, co-location, and telemedicine) between an MAT and community mental health organizations).

Project Echo Learning Community 10 Health Centers across the country Case Consultation Platform Increase use of MAT - buprenorphine

SBIRT Hilton Projects Reducing Adolescent Substance abuse initiative 26 CBHOs implement and sustain SBIRT among adolescents with mental health issues (3 years) 4 years: Achieving SBIRT practice Transformation (4 Years) -Kickoff was April 1. -Change Package SBIRT implementation Adolescents -Learning Collaborative

CIHS – Primary Care SBIRT MAT Screening Data Outcomes

Future CDC Funding – Commercial Health Plan Convening and regional state meetings Ongoing support for Mat and SUD in primary care Health Cares Conference for Behavioral Health Integration with Health Justice System