1. What would it take to get to zero overdose deaths in California?
Kelly Pfeifer, MD
May 5, 2017

2. No financial interests to disclose.

3. Beth
But I will disclose I was part of the problem generation – that thought we were helping people by treating their chronic pain with opioids.
Name and picture changed

4. Over the last decade, came to realize we are thinking about things wrong.
If you present in the ED with cardiac arrest vs. respiratory arrest from opioids
It is less dangerous to leave the ED with a missed MI than leave the ED after an opioid overdose

5. October June 1947
early 1990s

6. Starting the epidemic spreads like ether
Patient
Prescriber
Short
Term
Ether spread because it solved problems for the patient and the doctor, in the moment, instantly – as does opioid prescribing.
The problem with opioid prescribing comes months or years later, far from the moment of that initial prescribing decision.
Long Term

7. But reversing it? Like hand-washing
Work up front, pay off long in the future
Patient
Prescriber
Hand-washing costs time and effort in the short term with no immediate benefit. Surgical infections happened days or weeks later, and weren’t felt by the surgeon.
Likewise, reversing the epidemic requires a lot of work up front for the patient AND prescriber. And the pay-off will take months or years.

8. Pay-off: Drop in Overdose Deaths
This slide was a game-changer for me – when I heard Andrew Kolodny give a key note, and he compared two populations:
Stigmatized, blamed for disease, kicked out of health care settings, and the death rate did not drop until effective medications were deployed broadly outside specialty settings and made available to all who needed them – including ways to make them affordable.
Credit: Andrew Kolodny, MD

9. California context: how to change when change is hard
Step 1: Clear vision and goal
Step 2: Build partners and align work
Step 3: Pull many levers at once
Step 4: Use data: mark progress, course correct

10. Step 1: Clear vision and goal Zero Overdoses in California
FRANCE: Heroin OD vs treatment rates
Why not – every overdose is preventable
We know how to prevent overdose deaths
Credit: Andrew Kolodny, MD

11. Urgency: Death Rate Scenarios
Inadequate MAT access
There will never be enough methadone access to treat the demand.
Adequate MAT access
2000
2005
2010
2015
2020
2025

12. Del Norte
Modoc
Siskiyou
H&SS
Hubs
Shasta
Lassen 2
Humboldt
Trinity 5
Plumas
Tehama
Mendocino
Glenn
Butte 4 `
Sierra 1
Nevada
Lake
Yuba
Colusa
Placer
Sutter 12
Yolo 3
El Dorado
Sonoma 9
Napa
Sacramento
Amador
Alpine
Solano 16
Marin 11
Calaveras
Tuolumne
Contra Costa 7 6 8
San Joaquin
Mono
San Francisco
Alameda
Mariposa
Stanislaus
San Mateo 13
Santa Clara 13
Merced
Madera
Santa Cruz 14
Fresno 15
San Benito
Inyo
Monterey
Tulare
If we just counted on hubs – we would be nowhere close to covering the state
Kings
San Luis Obispo
Kern
San Bernardino
Santa Barbara
Ventura
Los Angeles 10 18
Riverside
Orange 19
Imperial
San Diego 17

13. Network # & Hub location
Del Norte
Modoc
Siskiyou
H&SS
Hubs and Spokes
Shasta
Lassen 2
Humboldt
Trinity 5
Network # & Hub location
Spokes 1
Lake County (1)
Mendocino County (2)
Nevada County (1) 2
Siskiou County (2)
Trinity County (1)
Del Norte County (1) 3
El Dorado County (1)
Placer County (1) 4
Butte County (2)
Lassen County (1)
Tehama County (1)
Plumas County (1) 5
Humboldt County (6) 6
San Joaquin County (1)
Stanislaus County (1) 7
Contra Costa County (TBD) 8
San Francisco County (TBD) 9
Sonoma County (1)
Yolo County (1)
Colusa County (1)
Napa County (1) 10
Los Angeles County (10) 11
Marin County (8) 12
Yolo County (2)
Sacramento County (1) 13
Santa Cruz - N County (6) 14
Santa Cruz - S County (4)
San Benito County (1)
Monterey County (1) 15
Fresno County (TBD) 16
Solano County (TBD) 17
San Diego County (7) 18 19
San Bernadino County (1)
Riverside County (6)
San Diego County (2)
Plumas
Tehama
Mendocino
Glenn
Butte 4
Sierra 1
Nevada
Lake
Yuba
Colusa
Placer
Sutter 3
El Dorado
Sonoma 12
Yolo 9
Napa
Sacramento
Amador
Alpine 16
Solano
Marin 11
Calaveras
Tuolumne
Contra Costa 6 8 7
San Joaquin
Mono
San Francisco
Alameda
Mariposa
Stanislaus
San Mateo 13
Santa Clara
Merced
Madera
Santa Cruz 14
Fresno 15
San Benito
Inyo
Monterey
Tulare
Even with adding the spokes – there are many white spaces – and some spaces with color (like the Inland Empire) only have one spoke.
We have work to do.
Kings
San Luis Obispo
Kern
San Bernardino
Santa Barbara
Ventura
Los Angeles 10 18
Riverside
Orange 19
Imperial
San Diego 17

14. That, I think, was the answer.
Step 2: Build partners
“Why did you listen to her?”
Nurse: “I didn’t. Then things changed.”
“Why?”
“She was nice. She smiled a lot.”
“That was it?”
Partnership is the key answer to solving this problem – we need to get comfortable to talking to people who were “other.”
We need to strip away judgment and keep our eyes on the prize – MAT access across the state.
“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”
That, I think, was the answer.
Source: Gawande, Slow Ideas

15. Partners California Department of Public Health
Statewide Opioid Safety Workgroup
Taskforces on policy, data, treatment, communications
Smart Care CA
Partnership between payers (Covered California, Medi-Cal,
CalPERS), plans and providers to reverse the opioid epidemic
Treating Addiction in Primary Care learning collaborative
25 community health centers learning MAT integration
California Opioid Safety Coalitions Network
36 counties working on safer prescribing, MAT and naloxone

16. Step 3: Pull many levers at once
Policy
Health plans
Providers:
Opioid treatment programs
Community health centers
County mental health clinics
Telehealth providers
Groups (scalable primary care buprenorphine model)
Local coalitions

17. 36 counties and growing…
To create local culture change, we charged regions to do all three things at once: safer prescribing, MAT and naloxone
This is our big bet.
Brought to you a proposal for 10 counties.
Now 17 coalitions, 24 counties
Cofunding:
Partnership Health Plan
Santa Clara County
CDPH
Offer:
Training (in –person and by webinar)
Coaching – one of the most effective tools, along with connecting of best practices
Physician mentors (this is how we did it)
Convenings – connecting with others solving similar problems
Modest core support – to pay for someone to set up meetings, take notes, put up dashboards – do the grunt work that gets things done.

19. Power of coalitions: emergency department guidelines
First step – stop ED supply of opioids into community
Next step: EDs as the first step of medication treatment for addiction

20. Power of coalitions: medication-assisted treatment
MAT in primary care
MAT in emergency depts
Buprenorphine trainings
Health plan incentives
Hub and Spoke programs

21. Power of coalitions: naloxone
Library anecdote

22. 74% decrease in total prescriptions and unsafe doses
Power of health plan/coalition partnership
Find what works and spread it – health plan
74% decrease in total prescriptions and unsafe doses
Partnership HealthPlan (14 Northern California counties)

23. Groups
CHCF invested in Groups to bring a low-cost, scalable buprenorphine model to the California safety net.
Possible spoke in H&SS, in hard-to-reach areas.

24. California Opioid Overdose Surveillance Dashboard
Step 4: Use Data, Mark Progress, Course Correct
California Opioid Overdose Surveillance Dashboard

25. Summary Hard problems need systems solutions. Prevention:
Safer prescribing practices:
fewer uses, lower doses, shorter durations Prevent new starts for opioid-naïve
Manage risk and function for pain patients
DO NO HARM
Medication-Assisted Treatment: ensure effective, accessible treatment
3. Naloxone: save lives

26. Director, High-Value Care California Health Care Foundation
Kelly Pfeifer, MD
Director, High-Value Care
California Health Care Foundation