SIHC MAT PROGRAM Hafifa Shabaik, PhD, RN, Quality Measures RN/Program Coordinator Young Suh, MD Medical Director/Program Director Southern Indian Health Council, Inc. February 2019

Opioid Crisis

Drug Overdose Deaths in the U.S. Number of Drug Overdose Deaths Per Year 2017 More than 4 times higher than 1999 More than peak HIV deaths in 1995 More than peak gun deaths in 1993 More than peak car crash deaths in 1972 https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html NCHS, National Vital Statistics System, Mortality SOURCES:

Opioid Overdose Deaths in the U.S. 1999 – 2016 Drug overdose deaths continue to increase in the United States. From 1999 to 2016: More than 630,000 people have died from a drug overdose. More than 350,000 (56%) people died from an overdose involving any opioid, including prescription and illicit opioids. And 66% in 2016 alone. In 2016, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 5 times higher than in 1999. On average, 115 Americans die every day from an opioid overdose. For American Indians and Alaska Natives, 8.4 per 100,000 experience opioid related fatalities, representing 3 times the death rate for Black Americans and Hispanic Whites. SPEAKER NOTES: This rise in opioid overdose deaths can be outlined in three distinct waves. The first wave began with increased prescribing of opioids in the 1990s , with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999. The second wave began in 2010, with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids – particularly those involving illicitly-manufactured fentanyl (IMF). The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine.  SOURCES: https://www.cdc.gov/drugoverdose/epidemic/index.html

THE OPIOID EPIDEMIC Pharmaceutical Companies Healthcare System Claimed that prescription opioids were not addictive Healthcare System Physicians began to prescribe opioids at greater rates Addictive Properties Misuse, abuse and diversion led to the spread of addiction and opioid overdoses Cheaper Alternatives Illicit manufacturing drastically increasing the number of deaths from opioids. *Roughly 25% of patients misuse prescribed Opioids for chronic pain *80% of Heroin users misused prescription opioids first

OPIOIDS What is an opioid? Derived from opium, that activate opioid receptors, commonly used for pain relief. Includes: Prescription opioids: hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine, codeine, and fentanyl. Illicitly produced opioids: heroin and fentanyl. Opioids used in medication assisted treatments: Methadone and buprenorphine (Suboxone)

Of people prescribed opioids for chronic pain develop OUD1. DEVELOPING OUD Opioids reduce the sensation of pain broadly and can make a person feel relaxed and produce a state of euphoria. When used for extended time or without medical need, one can develop opioid dependence/opioid use disorder. “Uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.” Believed to be associated with the brain’s reward pathways (dopamine). Ending the use of opioids can be difficult on one’s own. There is no one treatment option best for everyone, but medications are available to assist patients in their path toward wellness and recovery. 8-12% Of people prescribed opioids for chronic pain develop OUD1. 1 – NIH National Institute on Drug Abuse

SIHC Approach safe, effective, non-addictive strategies to manage chronic pain new, innovative medications and technologies to treat opioid use disorders improved overdose prevention and reversal interventionsto save lives and support recovery

MEDICATION-ASSISTED TREATMENT (MAT) Wellness Behavioral health Social services Primary care Traditional health Medication Assisted Treatment (MAT) is the use of federally approved medications, in combination with counseling and behavioral health therapies, to provide a “whole- patient” approach to the treatment of substance use disorders. Opioid Use Disorder

MAT AT SIHC The Office-Based MAT Program at SIHC is a funded program through the Tribal Opioid Response Grant by the Substance Abuse and Mental Health Services Administration. The goals of the MAT program is to increase access to medication assisted treatment for opioid use disorder in our community by providing: Increasing # providers with DEA waivers Referral to counseling/behavioral health services Care coordination Drug screening Prescription drug monitoring Community outreach and education

(MAT) MEDICATION ASSISTED TREATMENT The use of medications in conjunction with behavioral therapies and counseling to treat substance use disorder and prevent overdose. Medication Methadone Buprenorphine Naltrexone Mechanism Agonist Partial Agonist Antagonist Reduce/eliminate withdrawal symptoms X Block effects of other opioids Reduce/eliminate opioid cravings Methadone: Clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it. Naltrexone: Office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection. Buprinorphine: Office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk. A partial agonist medication that does not reproduce opioid effects even at higher doses and thus has lower abuse liability

OPIOID OVERDOSE The brain has many receptors for opioids. An overdose occurs when too much of an opioid (heroin, OxyContin, Percocet) fits in too many receptors, stopping the person’s breathing. Naloxone has a stronger affinity to the opioid receptors than opioid drugs, so it knocks the opioids off the receptors for a short time. This allows the person to breathe again and reverses the overdose.

CHALLENGES IN MAT Stigma Stigma continues to be the primary obstacle in increasing a community’s capacity to address this epidemic. Treatment availability gap Classic forms of treatment and culture may not be supportive

ADRESSING CHALLENGES Stigma Treatment availability gap: Community Outreach and Education at health fairs and events MAT on ROAM Practice non-judgement (educate staff and providers about appropriate language and terms) Treatment availability gap: Encouraging providers at SIHC to obtain DEA waivers to prescribe buprenorphine Collaborating with Kumeyayy Family Services and La Posta Substance Abuse Centers To increase access to counseling Referral to Behavioral Health Services Honoring cultural beliefs and practices By ensuring that our policy and procedures emphasize the community and family, the importance of relationships and respect for clients, especially elders and practice an open-door policy.

References Eidman, M. & Antony, V. (2018). DHCS Tribal MAT Project Powerpoint Presentation. California Consortium for Urban Indian Health. Legha, R., Raleigh-Cohn, A., Fickenscher, A., & Novins, D. (2014). Challenges to providing quality substance abuse treatment services for American Indian and Alaska Native communities: perspectives of staff from 18 treatment centers. BMC psychiatry, 14, 181. Rieckmann, T., Moore, L., Croy, C., Aarons, G. & Novins, D. (2017). National overview of medication-assisted treatment for American Indians and Alaska Natives with substance use disorders. Psychiatric Services, 68(11). Substance Abuse and Mental Health Services Administration (2018). Medication-Assisted Treatment. Retrieved from: https://www.samhsa.gov/medication-assisted-treatment Venner, K. L., Donovan, D. M., Campbell, A., Wendt, D. C., Rieckmann, T., Radin, S. M., Momper, S. L., … Rosa, C. L. (2018). Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives. Addictive Behaviors, 86, 111-117.