1. Public Health Conference March 3, 2016

2.  Recognize the merger of opioid abuse and disease transmission  Identify Missouri opioid abuse data components  Describe an example of a community level intervention  Explain the approach of DHSS’ Rx Drug Misuse Workgroup

3.  Spring, 2015  First ever DHS action for public health needs  HIV and HCV outbreak in Indiana  First ever DHSS participation  Three Disease Intervention Specialists (DIS) deployed to Indiana

4. Broadway Blvd., Austin IN

5.  December, 2014 – 3 new HIV diagnoses in Austin, IN (Scott County)  January, 2015 - 8 more new HIV infections  Typically, fewer than five cases of HIV infection are reported annually in Scott Co, IN.

6.  February, 2015 - Outbreak officially identified  Through efforts of a single DIS assigned to SE Indiana  March, 2015 - Public Health Emergency declared in Scott County

7.  Implementation of Indiana Executive Order provided for:  Establishing an incident command center to coordinate HIV intervention and prevention, and substance abuse treatment  Free HIV testing & utilization of rapid HIV screening  Increased interviewing of newly identified positive persons to elicit needle sharing and sex partners  Referral to medical and HIV care

8.  Executive Order also:  Launched a medical clinic  Provided assistance for Healthy Indiana Plan Insurance applications  Created and implemented education and prevention messages, “You Are Not Alone”  Enacted a targeted, short-term needle exchange program for the sole purpose of containing the epidemic  Needle exchange programs are illegal in Indiana

9. One-Stop-Shop Flyer Needle Exchange Info Card April 4, 2015 - Needle Exchange and One Stop Shop opened

10. Scott County One-Stop-Shop Needle Exchange Entrance

11.  February, 2016 - State health officials announced that the number of HIV cases in the Southeastern Indiana outbreak is 188  The majority of cases were linked to syringe- sharing partners injecting the prescription opioid oxymorphone aka “Opana” For more Indiana Health Department updates see this link: http://www.in.gov/isdh/26649.htm http://www.in.gov/isdh/26649.htm

12.  As of June, 2016:  Total Individuals Participating: 189  Estimated Needles Brought In: 27,878  Includes needles supplied by the program and within the community  Total Needles Provided: 28,671 Source: http://www.in.gov/isdh/files/June_19_State_Health_Officials_Discuss_Long_Term_Planning_Process_for_HIV_Outbreak_Response_and_Transition_.pdf

13.  491 IDU and sexual partners (contacts) elicited by DIS  46 unlocatable  16 other (out of jurisdiction, deceased, etc.) Source: Indiana Long-Term Planning Process Update http://www.in.gov/isdh/files/Briefing_Update_on_Long_Term_Planning_Process_for_Scott_County(3).pdf

14.  408 contacts located and offered testing  21 refused testing  169 HIV positive  86% co-infected with HCV  145 HCV positive Source: Indiana Long-Term Planning Process Update http://www.in.gov/isdh/files/Briefing_Update_on_Long_Term_Planning_Process_for_Scott_County(3).pdf

15.  Since 2010 Scott County has ranked 92 nd out of Indiana’s 92 counties in Health Outcomes*  Almost 19% of Scott County’s population live below the poverty line*  2014 unemployment rate 9.8%*  Austin, Indiana, the epicenter of the Outbreak in Scott County had a 25.8% unemployment rate** *Source: http://www.countyhealthrankings.org/app/indiana/2014/rankings/scott/county/outcomes/overall/snapshot ** Source: http://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml?src=bkmk

16.  Large rural, medically underserved areas  Limited needle exchange programs in MO (1 in KC)  Drug paraphernalia laws that include syringes  Requirement to Disclose (+)HIV infection statutes that carry legal penalties  Lack of opioid prescription tracking system  Increasing ED visits related to Intravenous Drug Use

17. Andrew Hunter, DHSS—Bureau of Health Care Analysis & Data Dissemination

18. Could the Indiana scenario happen in Missouri?

19. Data contributed by the Bureau of Vital Statistics

20. http://health.mo.gov/data/focus/index.php

23. 2014 Figures:  U.S. Rate=14.7  Missouri Rate=18.2 (tied for 14 th highest among all states)  Indiana Rate=18.2 Source: CDC, MMWR, Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014 Reported rates are age-adjusted per 100,000 population

24. Opioid Rates: U.S. Rate = 7.5 Missouri Rate = 9.8 Heroin Rates U.S. Rate=1.8 Missouri Rate=3.7 Source: CDC Wonder Reported rates based on 2008-2014 are age-adjusted per 100,000 population

26. Data contributed by the Bureau of Health Care Analysis and Data Dissemination

27. All inpatient/ER counts/rates in this presentation include only records with an opioid poisoning listed as the primary diagnosis on the discharge record.

30. Which groups in Missouri are most impacted by opioids?

35. Data presented on this slide is for non-Hispanic population only

36. Percent change values compare the 2008-2014 rates to the 2001-2007 rates.

39. These rates represent only non-Hispanic residents.

40. Percent change values compare the 2008-2014 rates to the 2001-2007 rates.

43. What areas of Missouri are most impacted?

45. Rate per 100,000 Population

47. Crude Rate per 100,000 Population

48. Crude Rate per 100,000 Population

50. Rate per 100,000 Population

54. Source: Riverfront Times and Missouri Hospital Association FY 2005 through FY 2014 inpatient and outpatient hospital discharge databases and Nielsen-Claritas 2014 PopFacts Premier. Z-scores calculated at the ZIP level using the rate of hospital visits between 2005 and 2014 per 10,000 residents. ZIPs with fewer than 50 residents were omitted.

55.  Missouri has high death and hospital utilization rates compared to national figures for opioids, especially heroin.  Rates are increasing in Missouri at a brisk pace. The 2014 opioid death rate is nearly 5 times higher than the 2001 rate. The heroin death rate is 15 times higher.  Heroin rates are highest among males, African- Americans and younger adult age groups (18- 24, 25-34).

56.  Heroin rate increases are highest for whites of both genders and younger age groups.  High death and hospital utilization rates for non-heroin opioids are highest in the southeast and southwest areas of the state.  High heroin death and hospital utilization rates are clustered in the St. Louis area.

57. Rx Drug Misuse Workgroup Dean Linneman, Deputy Director, Division of Regulation and Licensure

58. Rx Drug Misuse Workgroup The Workgroup is a multi-agency, multi- association group. Participants include:

59. Rx Drug Misuse Workgroup Four-pronged approach to building a solution: Creation of a Rx Drug Monitoring Program Alleviating Rx Drug Misuse Rx Drug Monitoring Program

60. Rx Drug Misuse Workgroup

61. Four-pronged approach to building a solution: Increased Education and Awareness Rx Drug Monitoring Program Education Alleviating Rx Drug Misuse

62. Rx Drug Misuse Workgroup

63. Four-pronged approach to building a solution: Increased Treatment/Therapy Options Education Rx Drug Monitoring Program Treatment and Therapy Options Alleviating Rx Drug Misuse

64. Rx Drug Misuse Workgroup Medication-Assisted Treatment  Medication-Assisted Treatment (MAT) is treatment for opioid addiction that uses medications such as methadone or buprenorphine to treat addiction to short-acting opioids, such as heroin, morphine and codeine, as well as synthetic opioids, including oxycodone, OxyContin®, and hydrocodone.

65. Rx Drug Misuse Workgroup Medication-Assisted Treatment  Methadone, when used in MAT can only be dispensed (not prescribed) in an Opioid Treatment Program (OTP). o (http://dmh.mo.gov/ada/docs/opioidtreatmentdirectory.pdf)  Office-based treatment for opioid addiction using buprenorphine is available from physicians who meet certain qualifications.

66. Rx Drug Misuse Workgroup Four-pronged approach to building a solution: Pain Clinic Regulation Rx Drug Monitoring Program Education Pain Clinic Regulation Treatment and Therapy Options Alleviating Rx Drug Misuse

67. Rx Drug Misuse Workgroup Pain Clinic Regulation

68. Rx Drug Misuse Workgroup Alleviating Rx Drug Misuse Treatment and Therapy Options Rx Drug Monitoring Program Education Pain Clinic Regulation The Final Product.

69.  Recognize the merger of opioid abuse and disease transmission  Indiana IDU linkage to HIV/HCV transmission  Identify Missouri opioid abuse data components  Missouri trends vs. national

70.  Describe an example of a community level intervention  KC Care Xchange  Explain the approach of DHSS’ Rx Drug Misuse Workgroup  Four-pronged effort