Pain Management and Substance Use Disorders: JCPP Strategic Session Christopher M. Jones, PharmD, MPH Director, National Mental Health and Substance Use Policy Laboratory Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

Outline Provide a brief background on the crisis Provide background on the opioid epidemic from the national policy perspective Current policies Policy pipeline Where pharmacists can play a role  What actions pharmacy can take

Outline Provide a brief background on the crisis Provide background on the opioid epidemic from the national policy perspective Current policies Policy pipeline Where pharmacists can play a role  What actions pharmacy can take

Origins of the epidemic and a path to solutions Increases in opioid-related harms fundamentally tied to two primary issues 1. Significant rise in opioid prescribing that began in the mid-to-late 1990s Prescribing opioids for different types of chronic pain conditions that we now know do not often benefit from opioids in the long-term Prescribing higher doses and for longer durations Prescribing opioids in combination with medications like benzodiazepines which can substantially increase risk for overdose 2. Lack of health system and provider capacity to identify, engage, and provide high-quality, evidence-based opioid addiction treatment, in particular mediation-assisted treatment with naltrexone, buprenorphine, or methadone Majority of people with opioid addiction in the U.S. do not receive treatment Even among those who do get treatment, many do not receive evidence-based care Lack of access to and provision of treatment is a significant contributor to rising rates of heroin and fentanyl use, rates of injection drug use, and overdose death

Snapshot of Rx opioid misuse and heroin use in 2016 Source: National Survey on Drug Use and Health, 2016

Infectious disease consequences – HCV and HIV HIV outbreak in Scott County, Indiana Phenomenon of multiple injections per injection episode (MIPIE) MIPIE comprised 2-4 injections during an injection episode resulting from needing >1 mL water to prepare Opana® ER solution using 1 mL syringes and frequent use of "rinse shots." MIPIE occurred up to 10 times/day (totaling 35 injections/day), often in the context of sharing drug and injection equipment. Source: Zibbell, AJPH, 2018; Wejnert MMWR 2016; Peters NEJM 2016, Broz IJDP, 2018

Rising rates of neonatal abstinence syndrome (NAS) and foster care placements Source: Winkelman et al, Pediatrics 2018; HHS/ACF: https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport24.pdf, 2017

Unprecedented increase in overdose deaths in U.S Opioids Cocaine Heroin Source: CDC WONDER, 1968-2016

Opioid overdose deaths at unprecedented levels Source: CDC National Vital Statistics System

Co-occurring substance use and mental illness among people with an opioid use disorder Source: Jones CM Unpublished Analysis of the National Survey on Drug Use and Health PUF, 2016

Outline Provide a brief background on the crisis Provide background on the opioid epidemic from the national policy perspective Current policies Policy pipeline Where pharmacists can play a role  What actions pharmacy can take

HHS Opioid Strategy Improving access to prevention, treatment, and recovery support services Targeting availability and distribution of overdose-reversing drugs Strengthening timely public health data and reporting Supporting cutting-edge research Advancing the practice of pain management

Strategic Policy Response Change opioid prescribing practices and expand access to and provision of opioid alternatives Maximize use of PDMPs Operationalize clinical guidelines for pain management Support innovative team-based approaches to pain care Align payment policies to facilitate access to evidence-based pain care Identify people with opioid use disorder early and directly provide or connect them to medication assisted treatment Increase screening to identify people with problematic opioid use Increase number of opioid treatment programs, number of providers with a DATA 2000 waiver, and number of clinicians providing extended-release naltrexone Implement innovative service delivery models to reach at-risk populations and increase treatment engagement and retention Align payment policies to facilitate expansion of MAT Support long-term recovery Establish recovery support services and recovery communities Ensure that people leaving treatment or transitioning from early-phase treatment are connected to the supports they need to achieve long-term recovery (e.g., housing, employment, peer supports) Expand access to naloxone Increase the co-prescription of naloxone to patients at risk of an overdose Maximize the reach of standing orders and other non-patient specific prescription strategies for obtaining naloxone Ensure naloxone is being provided to high-risk individuals at critical points in time (e.g., leaving CJ system, residential treatment, ED or hospitalization) Align payment policies and develop sustainable models for first responders and community-based programs to procure naloxone Collaborate with law enforcement to ensure a coordinated demand and supply reduction response

Opportunities for pharmacists Educate the public, patients, providers, and policymakers Check PDMP and discuss concerns with patients and prescribers and support efforts to integrate PDMPs, EHRs, and other data streams to improve care Follow pain care guidelines and engage with prescribers and patients on appropriate pain care, including self care, OTC options, and non-opioid treatments Engage in multidisciplinary teams to advance evidence-based pain care and addiction treatment Explore innovative MAT delivery approaches that involve pharmacies Implement pharmacy-based naloxone programs Conduct research to identify effective policies, programs, and practices Participate in coalitions and other collaborations

Outline Provide a brief background on the crisis Provide background on the opioid epidemic from the national policy perspective Current policies Policy pipeline Where pharmacists can play a role  What actions pharmacy can take

What actions pharmacy can take Pain care Substance use disorder

Questions? Christopher.Jones@samhsa.hhs.gov