1. Pain Management and Substance Use Disorders: JCPP Strategic Session
Christopher M. Jones, PharmD, MPH
Director, National Mental Health and Substance Use Policy Laboratory
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

2. Outline Provide a brief background on the crisis
Provide background on the opioid epidemic from the national policy perspective
Current policies
Policy pipeline
Where pharmacists can play a role 
What actions pharmacy can take

3. Outline Provide a brief background on the crisis
Provide background on the opioid epidemic from the national policy perspective
Current policies
Policy pipeline
Where pharmacists can play a role 
What actions pharmacy can take

4. Origins of the epidemic and a path to solutions
Increases in opioid-related harms fundamentally tied to two primary issues
1. Significant rise in opioid prescribing that began in the mid-to-late 1990s
Prescribing opioids for different types of chronic pain conditions that we now know do not often benefit from opioids in the long-term
Prescribing higher doses and for longer durations
Prescribing opioids in combination with medications like benzodiazepines which can substantially increase risk for overdose
2. Lack of health system and provider capacity to identify, engage, and provide high-quality, evidence-based opioid addiction treatment, in particular mediation-assisted treatment with naltrexone, buprenorphine, or methadone
Majority of people with opioid addiction in the U.S. do not receive treatment
Even among those who do get treatment, many do not receive evidence-based care
Lack of access to and provision of treatment is a significant contributor to rising rates of heroin and fentanyl use, rates of injection drug use, and overdose death

5. Snapshot of Rx opioid misuse and heroin use in 2016
Source: National Survey on Drug Use and Health, 2016

6. Infectious disease consequences – HCV and HIV
HIV outbreak in Scott County, Indiana
Phenomenon of multiple injections per injection episode (MIPIE)
MIPIE comprised 2-4 injections during an injection episode resulting from needing >1 mL water to prepare Opana® ER solution using 1 mL syringes and frequent use of "rinse shots."
MIPIE occurred up to 10 times/day (totaling 35 injections/day), often in the context of sharing drug and injection equipment.
Source: Zibbell, AJPH, 2018; Wejnert MMWR 2016; Peters NEJM 2016, Broz IJDP, 2018

7. Rising rates of neonatal abstinence syndrome (NAS) and foster care placements
Source: Winkelman et al, Pediatrics 2018; HHS/ACF:

8. Unprecedented increase in overdose deaths in U.S
Opioids
Cocaine
Heroin
Source: CDC WONDER,

9. Opioid overdose deaths at unprecedented levels
Source: CDC National Vital Statistics System

10. Co-occurring substance use and mental illness among people with an opioid use disorder
Source: Jones CM Unpublished Analysis of the National Survey on Drug Use and Health PUF, 2016

11. Outline Provide a brief background on the crisis
Provide background on the opioid epidemic from the national policy perspective
Current policies
Policy pipeline
Where pharmacists can play a role 
What actions pharmacy can take

12. HHS Opioid Strategy
Improving access to prevention, treatment, and recovery support services
Targeting availability and distribution of overdose-reversing drugs
Strengthening timely public health data and reporting
Supporting cutting-edge research
Advancing the practice of pain management

13. Strategic Policy Response
Change opioid prescribing practices and expand access to and provision of opioid alternatives
Maximize use of PDMPs
Operationalize clinical guidelines for pain management
Support innovative team-based approaches to pain care
Align payment policies to facilitate access to evidence-based pain care
Identify people with opioid use disorder early and directly provide or connect them to medication assisted treatment
Increase screening to identify people with problematic opioid use
Increase number of opioid treatment programs, number of providers with a DATA 2000 waiver, and number of clinicians providing extended-release naltrexone
Implement innovative service delivery models to reach at-risk populations and increase treatment engagement and retention
Align payment policies to facilitate expansion of MAT
Support long-term recovery
Establish recovery support services and recovery communities
Ensure that people leaving treatment or transitioning from early-phase treatment are connected to the supports they need to achieve long-term recovery (e.g., housing, employment, peer supports)
Expand access to naloxone
Increase the co-prescription of naloxone to patients at risk of an overdose
Maximize the reach of standing orders and other non-patient specific prescription strategies for obtaining naloxone
Ensure naloxone is being provided to high-risk individuals at critical points in time (e.g., leaving CJ system, residential treatment, ED or hospitalization)
Align payment policies and develop sustainable models for first responders and community-based programs to procure naloxone
Collaborate with law enforcement to ensure a coordinated demand and supply reduction response

14. Opportunities for pharmacists
Educate the public, patients, providers, and policymakers
Check PDMP and discuss concerns with patients and prescribers and support efforts to integrate PDMPs, EHRs, and other data streams to improve care
Follow pain care guidelines and engage with prescribers and patients on appropriate pain care, including self care, OTC options, and non-opioid treatments
Engage in multidisciplinary teams to advance evidence-based pain care and addiction treatment
Explore innovative MAT delivery approaches that involve pharmacies
Implement pharmacy-based naloxone programs
Conduct research to identify effective policies, programs, and practices
Participate in coalitions and other collaborations

15. Outline Provide a brief background on the crisis
Provide background on the opioid epidemic from the national policy perspective
Current policies
Policy pipeline
Where pharmacists can play a role 
What actions pharmacy can take

16. What actions pharmacy can take
Pain care
Substance use disorder

17. Questions?