ADDRESSING THE OPIOID CRISIS VERMONT’S RESPONSE

ADDICTION 101 Etiology: Genetics, stress, exposure Pathology: Primarily brain structure and function Symptoms: Radiating consequences Phenomenology: Suffering, misunderstood, stigmatized Treatment: Effective treatments, no cures

TOP GENERIC PRESCRIPTIONS WHAT’S #1? Hydrocodone + acetaminophen [Vicodin]( n=122,806,850) 18. Oxycodone + acetaminophen [Percocet] (n=28,705,243) 46. Propoxyphene + acetaminophen [Darvon] (n=14,274,354) 51. Oxycodone (n=12,652,375) 114. Fentanyl patch (n=4,914,785) 121. Methadone (n=4,558,532) 170. Morphine (n=2,740,358) 192. Hydromorphone [Dilaudid] (n=2,272,481) Top 200 generic drugs by units in 2010. SDI’s Vector One® National

PAIN IS BIG BUSINESS U.S. SPENDING (2014) IMS Health, National Prescription Audit, Dec 2013

OPIOID PRESCRIPTIONS HAVE SKYROCKETED OVER PAST 20 YEARS It has dropped a little bit in 2013 to 207 million.

OVERDOSE DEATHS FROM OPIOIDS INCREASED 200% SINCE 2000 CDC, 2014. National Center for Health Statistics, National Vital Statistics System

OVERDOSE DEATH IN VERMONT INCREASED IN EVERY COUNTY Source:  http://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/ NOTES: † Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug-poisoning deaths are defined as having ICD–10 underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent). ‡ Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files (1). Age-adjusted death rates (deaths per 100,000 U.S. standard population for 2000) are calculated using the direct method. Populations used for computing death rates for 2011–2014 are postcensal estimates based on the 2010 U.S. census. Rates for census years are based on populations enumerated in the corresponding censuses. Rates for noncensus years before 2010 are revised using updated intercensal population estimates and may differ from rates previously published. * Estimate does not meet standards of reliability or precision. Death rates are flagged as “Unreliable” in the chart when the rate is calculated with a numerator of 20 or less. § Smoothed county age-adjusted death rates (deaths per 100,000 population) were obtained according to methods described elsewhere (3–5). Briefly, two-stage hierarchical models were used to generate empirical Bayes estimates of county age-adjusted death rates due to drug poisoning for each year during 2002–2014. These annual county-level estimates “borrow strength” across counties to generate stable estimates of death rates where data are sparse due to small population size (3,5). Estimates are unavailable for Broomfield County, Colo., and Denali County, Alaska, in 2002; these counties did not appear in the mortality files until 2003 (6,7). Additionally, Bedford City, Virginia was added to Bedford County in 2014 and no longer appears in the mortality file in 2014. County boundaries are consistent with the vintage 2005-2007 bridged-race population file geographies (6) Source: Centers for Disease Control and Prevention, Drug Poisoning Mortality: United States, 2002-2014 January 2016

TRANSITION ACROSS THE U.S. FROM PRESCRIPTION OPIOIDS TO HEROIN

TRANSITION ACROSS THE NORTHEAST EVEN MORE DRAMATIC

WHAT ABOUT VERMONT? THE TRANSITION IS DEADLY Source: Vermont Department of Health Vital Statistics System Vermont Department of Health

WHY THE TRANSITION? FROM PRESCRIPTION OPIOIDS Some are expensive or have seen prices increase Many preferred opioids hard to find Abuse deterrent formulations Wiser providers New prescribing guidelines

WHY THE TRANSITION? TO HEROIN Cost and availability: Heroin is cheaper Heroin is easier to get Heroin is easier to inject Heroin is purer than ever

THE NEW HEROIN CONSUMER IF YOU PLAN ON PROFILING Previous era heroin users: Young, minority male living in urban centers Unemployed New era heroin users: Young and middle-aged, white male/female living in a suburban/rural area Employed

3 FDA-APPROVED MEDICATIONS FOR TREATING OPIOID USE DISORDERS* METHADONE BUPRENORPHINE NALTREXONE *MEDICATION-ASSISTED TREATMENT (MAT)

VERMONT’S RESPONSE A MODEL FOR THE REST OF THE COUNTRY Openly acknowledged by Governor as public health crisis Creation of “HUB” and “SPOKE” model HUB: Specialty care Opioid Treatment Programs (OTPs) for methadone, buprenorphine and naltrexone SPOKE: General Office-based Opioid Treatment (OBOT) practices for buprenorphine and naltrexone Financing and workforce to support practice Activities to increase access and availability--quantity Activities to ensure quality

PATIENT-CENTERED MEDICAL HOME ADDICTION AS CHRONIC MEDICAL CONDITION Specialty Care OTP Primary Care OBOT PCMH Community Health Team

OTP HUB GROWTH TRIPLED IN PAST 3 YEARS

OBOT SPOKE GROWTH MUCH SLOWER---ABOUT 30%

PROGRESS NOT PERFECTION BIG DENT, LITTLE DENT OR NO DENT AT ALL? Addiction has no silver bullet cure, medication is one component of the potential for a good outcome How long should medication be necessary? OBOT expansion in small to medium size practices but not in large or hospital practices Need to evaluate outcomes (costs $) Vision for recovery: With MAT or not