What would it take to get to zero overdose deaths in California? Kelly Pfeifer, MD kpfeifer@chcf.org May 5, 2017

No financial interests to disclose.

Beth But I will disclose I was part of the problem generation – that thought we were helping people by treating their chronic pain with opioids. Name and picture changed

Over the last decade, came to realize we are thinking about things wrong. If you present in the ED with cardiac arrest vs. respiratory arrest from opioids It is less dangerous to leave the ED with a missed MI than leave the ED after an opioid overdose

October 1846 June 1947 1867 early 1990s

Starting the epidemic spreads like ether Patient Prescriber Short Term Ether spread because it solved problems for the patient and the doctor, in the moment, instantly – as does opioid prescribing. The problem with opioid prescribing comes months or years later, far from the moment of that initial prescribing decision. Long Term

But reversing it? Like hand-washing Work up front, pay off long in the future Patient Prescriber Hand-washing costs time and effort in the short term with no immediate benefit. Surgical infections happened days or weeks later, and weren’t felt by the surgeon. Likewise, reversing the epidemic requires a lot of work up front for the patient AND prescriber. And the pay-off will take months or years.

Pay-off: Drop in Overdose Deaths This slide was a game-changer for me – when I heard Andrew Kolodny give a key note, and he compared two populations: Stigmatized, blamed for disease, kicked out of health care settings, and the death rate did not drop until effective medications were deployed broadly outside specialty settings and made available to all who needed them – including ways to make them affordable. Credit: Andrew Kolodny, MD

California context: how to change when change is hard Step 1: Clear vision and goal Step 2: Build partners and align work Step 3: Pull many levers at once Step 4: Use data: mark progress, course correct

Step 1: Clear vision and goal Zero Overdoses in California FRANCE: Heroin OD vs treatment rates Why not – every overdose is preventable We know how to prevent overdose deaths Credit: Andrew Kolodny, MD

Urgency: Death Rate Scenarios Inadequate MAT access https://www.statnews.com/2017/06/27/opioid-deaths-forecast/ There will never be enough methadone access to treat the demand. Adequate MAT access 2000 2005 2010 2015 2020 2025

Del Norte Modoc Siskiyou H&SS Hubs Shasta Lassen 2 Humboldt Trinity 5 Plumas Tehama Mendocino Glenn Butte 4 ` Sierra 1 Nevada Lake Yuba Colusa Placer Sutter 12 Yolo 3 El Dorado Sonoma 9 Napa Sacramento Amador Alpine Solano 16 Marin 11 Calaveras Tuolumne Contra Costa 7 6 8 San Joaquin Mono San Francisco Alameda Mariposa Stanislaus San Mateo 13 Santa Clara 13 Merced Madera Santa Cruz 14 Fresno 15 San Benito Inyo Monterey Tulare If we just counted on hubs – we would be nowhere close to covering the state Kings San Luis Obispo Kern San Bernardino Santa Barbara Ventura Los Angeles 10 18 Riverside Orange 19 Imperial San Diego 17

Network # & Hub location Del Norte Modoc Siskiyou H&SS Hubs and Spokes Shasta Lassen 2 Humboldt Trinity 5 Network # & Hub location Spokes 1 Lake County (1)   Mendocino County (2) Nevada County (1) 2 Siskiou County (2) Trinity County (1) Del Norte County (1) 3 El Dorado County (1) Placer County (1) 4 Butte County (2) Lassen County (1) Tehama County (1) Plumas County (1) 5 Humboldt County (6) 6 San Joaquin County (1) Stanislaus County (1) 7 Contra Costa County (TBD) 8 San Francisco County (TBD) 9 Sonoma County (1) Yolo County (1) Colusa County (1) Napa County (1) 10 Los Angeles County (10) 11 Marin County (8) 12 Yolo County (2) Sacramento County (1) 13 Santa Cruz - N County (6) 14 Santa Cruz - S County (4) San Benito County (1) Monterey County (1) 15 Fresno County (TBD) 16 Solano County (TBD) 17 San Diego County (7) 18 19 San Bernadino County (1) Riverside County (6) San Diego County (2) Plumas Tehama Mendocino Glenn Butte 4 Sierra 1 Nevada Lake Yuba Colusa Placer Sutter 3 El Dorado Sonoma 12 Yolo 9 Napa Sacramento Amador Alpine 16 Solano Marin 11 Calaveras Tuolumne Contra Costa 6 8 7 San Joaquin Mono San Francisco Alameda Mariposa Stanislaus San Mateo 13 Santa Clara Merced Madera Santa Cruz 14 Fresno 15 San Benito Inyo Monterey Tulare Even with adding the spokes – there are many white spaces – and some spaces with color (like the Inland Empire) only have one spoke. We have work to do. Kings San Luis Obispo Kern San Bernardino Santa Barbara Ventura Los Angeles 10 18 Riverside Orange 19 Imperial San Diego 17

That, I think, was the answer. Step 2: Build partners “Why did you listen to her?” Nurse: “I didn’t. Then things changed.” “Why?” “She was nice. She smiled a lot.” “That was it?” Partnership is the key answer to solving this problem – we need to get comfortable to talking to people who were “other.” We need to strip away judgment and keep our eyes on the prize – MAT access across the state. “It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.” That, I think, was the answer. Source: Gawande, Slow Ideas

Partners California Department of Public Health Statewide Opioid Safety Workgroup Taskforces on policy, data, treatment, communications Smart Care CA Partnership between payers (Covered California, Medi-Cal, CalPERS), plans and providers to reverse the opioid epidemic Treating Addiction in Primary Care learning collaborative 25 community health centers learning MAT integration California Opioid Safety Coalitions Network 36 counties working on safer prescribing, MAT and naloxone

Step 3: Pull many levers at once Policy Health plans Providers: Opioid treatment programs Community health centers County mental health clinics Telehealth providers Groups (scalable primary care buprenorphine model) Local coalitions

36 counties and growing… To create local culture change, we charged regions to do all three things at once: safer prescribing, MAT and naloxone This is our big bet. Brought to you a proposal for 10 counties. Now 17 coalitions, 24 counties Cofunding: Partnership Health Plan Santa Clara County CDPH Offer: Training (in –person and by webinar) Coaching – one of the most effective tools, along with connecting of best practices Physician mentors (this is how we did it) Convenings – connecting with others solving similar problems Modest core support – to pay for someone to set up meetings, take notes, put up dashboards – do the grunt work that gets things done.

Power of coalitions: emergency department guidelines First step – stop ED supply of opioids into community Next step: EDs as the first step of medication treatment for addiction

Power of coalitions: medication-assisted treatment MAT in primary care MAT in emergency depts Buprenorphine trainings Health plan incentives Hub and Spoke programs

Power of coalitions: naloxone Library anecdote

74% decrease in total prescriptions and unsafe doses Power of health plan/coalition partnership Find what works and spread it – health plan 74% decrease in total prescriptions and unsafe doses Partnership HealthPlan (14 Northern California counties)

Groups CHCF invested in Groups to bring a low-cost, scalable buprenorphine model to the California safety net. Possible spoke in H&SS, in hard-to-reach areas.

California Opioid Overdose Surveillance Dashboard Step 4: Use Data, Mark Progress, Course Correct California Opioid Overdose Surveillance Dashboard

Summary Hard problems need systems solutions. Prevention: Safer prescribing practices: fewer uses, lower doses, shorter durations Prevent new starts for opioid-naïve Manage risk and function for pain patients DO NO HARM Medication-Assisted Treatment: ensure effective, accessible treatment 3. Naloxone: save lives

Director, High-Value Care California Health Care Foundation Kelly Pfeifer, MD Director, High-Value Care California Health Care Foundation kpfeifer@chcf.org www.chcf.org