The Opioid Crisis – National and State Perspectives ARC 2019 CONFERENCE Greg Lakin, D.O., J.D. Center for Change - Out Patient Opioid Treatment Facility Former Medical Director of Kansas-Department of Health and Environment Chair of the former Governor’s Substance Use Disorder Task Force The Opioid Crisis – National and State Perspectives October 13, 2019

What is the Opioid Epidemic? The Opioid Crisis Nationally What is the Opioid Epidemic? To protect and improve the health and environment of all Kansans

The Problem The Opioid Crisis Nationally From 1999 to 2017, more than 700,000 people have died from a drug overdose. 400,000 (58%) of those overdose deaths, involved opioids. More than were ever killed by: guns, MVA, or HIV/AIDS in a single year. To protect and improve the health and environment of all Kansans

Division of Public Health The Opioid Crisis – National and State Perspectives Chart shows trend of drug poisoning death counts caused by all drugs in the U.S. from 1980 – 2016. There are more drug OD deaths in 2016 than there were for MVAs, AIDS in the height of the epidemic, and firearm-related deaths in any previous year Over the past 25-30 years, the U.S. sets a new record for drug poisoning deaths every year, and each successive year that record is broken. In comparing the drug OD mortality count in recent years to the crack cocaine epidemic in the 1980s, we have surpassed that 6 fold. To protect and improve the health and environment of all Kansans

Background Division of Public Health The Opioid Crisis – National and State Perspectives Background In 2016, there were 63,632 drug poisoning deaths in the United States 2017 provisional data – 70,467 deaths from 12/2016 – 12/2017 Drug poisoning is the leading cause of unintentional injury death in the U.S. Unintentional injuries became the 3rd leading cause of death in 2016 U.S. life expectancy decreased in 2015 and 2016 In 2016, there was a total of 63,632 drug overdose deaths in the United States. (One death every 12 minutes). Provisional data – is likely under-reported. Averages one death every 7.5 minutes. Unintentional drug poisonings are the number one cause of unintentional injury death nationwide, ahead of motor vehicle deaths and firearms deaths. Unintentional injuries became the 3rd leading cause of death in 2016, right behind cancer and cardiovascular disease Life expectancy decreased 0.1 year in both 2015 and 2016 because of this influx in drug OD deaths. Public health emergency To protect and improve the health and environment of all Kansans

The Opioid Crisis Nationally Drug poisonings are the leading cause of unintentional injury death in the U.S. Unintentional injuries became the 3rd leading cause of death in the U.S. in 2016 The U.S. population’s average life expectancy decreased by 0.1 year in both 2015 and 2016 2017 trending toward another drop in life expectancy due to drug related deaths. To protect and improve the health and environment of all Kansans

Division of Public Health The Opioid Crisis – National and State Perspectives This graph breaks down the U.S. drug overdoses by type of drug from 2000-2016. In looking at the drugs that are implicated in U.S. overdose deaths, prescription and illicit opioids are the most prevalent, and deaths involving opioids continue to increase. In 2016, opioid OD deaths accounted for 66% of all the drug overdose deaths. Essentially, opioids are driving the U.S. drug overdose epidemic. To protect and improve the health and environment of all Kansans

The Opioid Crisis Nationally Image Source: CDC. Available at: https://www.cdc.gov/drugoverdose/epidemic/index.html To protect and improve the health and environment of all Kansans

Division of Public Health The Opioid Crisis – National and State Perspectives 42,249 of the 63,632 U.S. drug overdose deaths involved a prescription or an illicit opioid This chart shows U.S. opioid overdose deaths specifically from 2000-2016 Opioids were involved in 42,249 of the 63,632 deaths in 2016 (that includes any opioid – heroin, rxs, legal and illegal fentanyl)…that’s about 66% of the total Equivalent to 116 opioid-overdose deaths every day in 2016…staggering statistic Doesn’t account for number of non-fatal opioid ODs The arrows reflect the 3 waves of the opioid epidemic: Natural and semi-synthetic – rises in 1999 and persists. Caused by influx of prescriptions in the 1990s Deaths caused by semi-synthetic opioids remained higher than deaths attributed to heroin and synthetic opioids in the 1990s-2000s 2. Heroin – rises sharply in 2010 – those younger individuals addicted to rxs switch to heroin because it’s cheap, accessible, and effects are virtually indistinguishable from prescription opioids Rx opioid exposure is a risk factor for heroin use as 8/10 heroin users report that their addiction began with rxs Have to maintain opioid supply once addicted Heroin use may be an outcome of OUD that started with rx opioids; especially after having no or difficulty with rehab 3. Synthetic – (fentanyl and >1400 analogs) sharply rises in 2013, and death rate actually doubled between 2015 and 2016 Causes the majority of opioid-overdose deaths in 2016!!! Fentanyl is 50-100x stronger than morphine, and up to 50x more potent than heroin so it is easy to OD on. Fentanyl overdoses have a fast onset (O2 deprivation), and are more difficult to reverse with narcan Illicitly manufactured in China and then shipped to the U.S. and cut into the heroin supply. Even cheaper than heroin. Also, fentanyl is also frequently involved in overdose deaths involving non-opioids drugs 40.3% of cocaine-involved overdose deaths 31.0% of benzodiazepine-involved overdose deaths 20.8% of antidepressant-related deaths Recently being mixed into methamphetamine, further increasing OD deaths To protect and improve the health and environment of all Kansans

National Drug Overdose Mortality Rates - Who Division of Public Health The Opioid Crisis – National and State Perspectives National Drug Overdose Mortality Rates - Who Gender – Males (26.2 deaths per 100,000) Age – 35-44 (35.0 deaths per 100,000) Race – Non-Hispanic whites (25.3 deaths per 100,000) Drug overdoses affect those of all ages, races, and socioeconomic statuses. Certain populations are affected by fatal drug overdoses at disproportionate rates as compared to others. Based on 2016 data, the age-adjusted mortality rate for non-Hispanic whites was 25.3 deaths per 100,000 U.S. population, 17.1 deaths per 100,000 U.S. population for non-Hispanic blacks, and 9.5 deaths per 100,000 U.S. population for Hispanics. Based on 2016 data, persons aged 35-44 had the highest mortality rate from drug poisonings (35.0 deaths per 100,000), followed by adults aged 25-34 (34.6 deaths per 100,000) and 45-54 (34.5 deaths per 100,000). This reflects a 29%, 24%, and 15% increase in drug overdose death rates from 2015 to 2016 per each respective cohort.17 However, the drug poisoning mortality rate also increased in persons aged 15-24, 55-64, and 65 and over – 28%, 17%, and 7%, respectively.17 Males are significantly more likely to die from drug poisonings as compared to females, though the gender gap is closing. In 2016, the drug poisoning mortality rate for males was 26.2 deaths per 100,000, compared to 13.4 deaths per 100,000 for females.17 In summarizing these data, the demographics of those who died from drug poisonings in the United States are mainly white non-Hispanic males between the ages of 25 to 54. This demographic remains consistent in focusing on opioid-related mortality specifically – though, the younger cohort (ages 25-34) are more likely to die from illicit opioid overdoses as opposed to the older cohort (ages 45-54). Image source: National Center for Health Statistics To protect and improve the health and environment of all Kansans

The Opioid Crisis Nationally Most who reported prescription opioid abuse prior to heroin cited accessibility and cost as primary factors for the heroin use/transition. Source: Cicero TJ, Ellis MS, Harney J. Shifting patterns of prescription opioid and heroin abuse in the United States. New England Journal of Medicine. 2015 Oct 29;373(18):1789-90. To protect and improve the health and environment of all Kansans

What is Happening in Kansas? The Opioid Crisis in Kansas What is Happening in Kansas? To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas To protect and improve the health and environment of all Kansans

Kansas Drug Poisoning Death Rates/Counts 2005-2016 The Opioid Crisis in Kansas Kansas Drug Poisoning Death Rates/Counts 2005-2016 To protect and improve the health and environment of all Kansans

Drug Poisoning Mortality in Kansas The Opioid Crisis in Kansas Drug Poisoning Mortality in Kansas 310 drug poisoning deaths in 2016 104 caused by natural or semi-synthetic opioids 36 caused by heroin Drug poisoning death rate decreased 8% in 2016 compared to 2015 To protect and improve the health and environment of all Kansans

1 2 3 4 What is K-TRACS? The Opioid Crisis in Kansas Secure, 24/7 web-accessible database, that monitors Schedule II-IV controlled substance prescriptions, and drugs of concern dispensed in Kansas 2 Pharmacies are required to report outpatient prescriptions daily. (Exempt – hospitals for inpatient care, LTC, veterinarians, hospice) 3 K-TRACS data is privileged and confidential Pharmacists and Prescribers MAY access De-identified data available for statistical, research or educational purposes 4 PMP Advisory Committee composed of prescribers and pharmacists meets quarterly and has authority to review/refer providers and patients What is K-TRACS? To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas Annual Average Age-adjusted Drug Poisoning Mortality Rate per 100,000 population by County, Kansas residents, 2010-2016 Data Source: 2010-2016 Kansas Bureau of Epidemiology and Public Health Informatics, Kansas Department of Health and Environment, Kansas Mortality Files. Only counties with at least 5 expected deaths per 100,000 population are shown due to unstable rates. To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas Annual Average Age-adjusted Opioid Poisoning Mortality Rate per 100,000 population by County, Kansas residents, 2010-2016 1,077 deaths from 2010 to 2016 were opioid-related deaths – any prescription opioids, heroin, or illicit opioid contributed to the death. Data Source: 2010-2016 Kansas Bureau of Epidemiology and Public Health Informatics, Kansas Department of Health and Environment, Kansas Mortality Files. Only counties with at least 5 expected deaths per 100,000 population are shown due to unstable rates. To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas Annual Average Age-adjusted Opioid Poisoning Mortality Rate per 100,000 population by County, Kansas residents, 2010-2016 Six counties in Kansas had a rate higher than the 2016 national average of 13.3. This is potentially an underestimate since there are drug poisoning deaths in Kansas that do not specific a drug. Data Source: 2010-2016 Kansas Bureau of Epidemiology and Public Health, Kansas Department of Health and Environment, Kansas Mortality Files. Only counties with at least 5 expected deaths per 100,000 population informatics are shown due to unstable rates. To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas Patients with concurrent prescriptions for opioids and benzodiazepine is a risk factor for opioid poisoning and developing an opioid use disorder. In 2017, there were 8 counties with at least 7% of county residents with concurrent prescriptions for opioids and benzodiazepine in 2017. Image Source: http://www.preventoverdoseks.org/kpdo_data.htm To protect and improve the health and environment of all Kansans

The Opioid Crisis in Kansas Having a mental illness, history of alcohol use disorder, or other substance use disorder is a risk factor for opioid poisoning and developing an opioid use disorder. County Level Prevalence of Depressive Disorder, Kansas BRFSS 2015 County Level Prevalence of Binge Drinker, Kansas BRFSS 2015 Numerator: Male respondents having five or more drinks on one occasion in the past 30 days or females having four or more drinks on one occasion in the past 30 days. Denominator: All respondents, excluding unknowns and refusals. Numerator: Respondents who reported they had ever been told by a doctor, nurse or other health professional that they have a depressive disorder (including depression, major depression, dysthymia, or minor depression). Denominator: All respondents, excluding unknowns and refusals. To protect and improve the health and environment of all Kansans

Decreasing the Risk in the High Risk Population in Kansas? The Opioid Crisis in Kansas Decreasing the Risk in the High Risk Population in Kansas? To protect and improve the health and environment of all Kansans

Kansas Response The Opioid Crisis in Kansas Established Kansas Prescription Drug and Opioid Advisory Committee to: Development and implementation of a statewide strategic plan across multiple sectors to facilitate primary, secondary, and tertiary prevention activities for prescription and illicit drug abuse and overdose Components: needs assessment, state plan, evaluation plan, and dissemination plan Advisory Committee provides support to Governor’s Substance Use Task Force. To protect and improve the health and environment of all Kansans

Kansas Response Substance Use Disorder Task Force The Opioid Crisis in Kansas Kansas Response Substance Use Disorder Task Force We have had six meetings since April 2018. The Task Force evaluated and prioritized recommendations by the Opiate Prescription Advisory Committee, as well as creating new recommendations in all aspects of SUD, including; prevention, education, neonatal abstinence syndrome, treatment, law enforcement and corrections. The SUD Task Force submitted its final recommendations to Governor Colyer Sept. 1. To protect and improve the health and environment of all Kansans

Advisory Committee The Opioid Crisis in Kansas To protect and improve the health and environment of all Kansans

Multidisciplinary Approach The Opioid Crisis in Kansas Multidisciplinary Approach A multi-faceted problem requires a multi-disciplinary approach Primary prevention – Prevent opioid use disorder Secondary prevention – Surveillance and early detection of OUD Tertiary prevention – Prevent mortality Harm reduction Access to treatment To protect and improve the health and environment of all Kansans

Recommendations The Opioid Crisis in Kansas To protect and improve the health and environment of all Kansans

WHAT CAUSES ADDICTION

- TOLERANCE

Who is Affected by the Epidemic? The Opioid Crisis in Kansas Who is Affected by the Epidemic? To protect and improve the health and environment of all Kansans

Patient started with use of Lortabs my mouth then started use of IV Herion…

IV USE Abscess areas of injection sites.

IV USE IV USE Patient started with use of Lortabs my mouth then started use of IV Herion…

IV USE Patient started with use of Lortabs my mouth then started use of IV Herion…

Reactive States > Reactive Mind TREATMENT = MOOD STABILIZATION Reactive States > Reactive Mind The part of the mind which works on a totally stimulus- response basis, which is not under a person’s volitional control, and which exerts force and the power of command over his awareness, purposes, thoughts, body and actions Possible reasons that mental illnesses and substance abuse tend to co-occur include: (1) the propensity for people to self-medicate in order to relieve mental distress or illness; (2) the increased risk for mental illness brought on by drug abuse, especially in those with genetic or other vulnerabilities; (3) the overlap of risk factors for both conditions. Live there long enough mind changes but can change back To protect and improve the health and environment of all Kansans

Thank you/Questions The Opioid Crisis in Kansas Greg Lakin, D.O., J.D. Center for Change Kansas Medical Director & Founder Out-Patient Opioid Medication Assisted Treatment Facility. Visit our Kansas website! www.preventoverdoseks.org To protect and improve the health and environment of all Kansans To protect and improve the health and environment of all Kansans

Treatment Options: We offer two different options to assist the patient: 1. Out Patient or In- Patient 2. Methadone/ Suboxone We assist the patient to set a treatment plan that they feel will work for them to reach their short term and long term goals.

It Is Real Opiate Overdose Perhaps the most serious effect of heroin is the risk of overdose. Because of variability in purity of the substance as well as lack of information regarding what is mixed into the drug, dosing is difficult to measure. Effects of overdose include: •Dangerously slowed breathing rate. •Depressed heart rate. •Loss of consciousness. • Permanent brain damage. •Coma. •Death.