1. OVERDOSE FATALITY REVIEW A THOUGHTFUL APPROACH TO PAIN MANAGEMENT MAY 29-30, 2015 Erin Haas Overdose Prevention Local Programs Manager

2. OVERDOSE FATALITY REVIEW Modeled after other mortality review teams (CFR, FIMR, etc.) Multi-agency/multi-disciplinary team assembled to conduct confidential case reviews of overdose deaths Goal to prevent future deaths by  Identifying missed opportunities for prevention and gaps in system  Building working relationships b/t local stakeholders on OD prevention  Recommending policies, programs, laws, etc. to prevent OD deaths  Informing local overdose prevention strategy Department of Health and Mental Hygiene (DHMH) provides TA & death records to teams Team members bring info from respective agencies about decedents to inform review 3 Pilot Teams → Baltimore City, Cecil County, Wicomico County

3. OVERDOSE FATALITY REVIEW Legal authority Pilot phase: medical review committees HB1282 passed and went into effect 10/1/14 OFR law (HB1282) gives structure and authority to the teams (membership, goals, etc.) provides civil liability protection for team members and those that provide information to the teams establishes confidentiality requirements establishes expectations and reporting requirement to DHMH TA continues to new and existing teams 11 new teams have begun reviewing cases Attending all first meetings Bimonthly conference calls

4. “The open communication will help resolve the barriers that we face in the community” “The meetings were stilted at first, but have been improving- nearly all members contribute to discussions, which are often lively, and we spend enough time on cases to generate ideas” “Its definitely helping us get to the story behind the numbers”

5. OPERATIONS Three pilot teams Cecil, Wicomico, Baltimore City Met at least quarterly, reviewed 86 cases from January – October 2014 Agencies involved: EMS Sheriff's Office Detention Center Court System Mental Health Treatment Social Services Community Supervision State's Attorney SEP/Staying Alive Pharmacy Drug Treatment (Public and Private) Hospital Board of Education Dept. Juvenile Services

6. DATA COLLECTION/REPORTING Meetings Demographics Date of death Cause of death Indication of data reviewed Key observations Trends, potential recommendations at policy, system and program level Data challenges Recommendation tracking Updated quarterly Reported to DHMH

7. CASES REVIEWED Total: 86 Pilot Phase: January – October 2014 Gender Male05151216113062 72% Female0185531124 28% Race/Ethnicity African American0253751023 Hispanic001010002 White041613 92158 Unknown001100103 <1818-2425-3435-4445-5455-6465+ Unkno wnTotal

8. AGENCY INTERACTION VA EMS Law Enforcement Detention Center Court System Mental Health Tx Social Services Community Supervision State's Attorney SEP/Staying Alive Pharmacy Drug Tx (Public and Private) Hospital 1 56 76 11 8 22 31 25 29 10 4 49 9 1 65% 88% 13% 9% 26% 36% 29% 34% 12% 5% 57% 10%

9. AGENCY INTERACTION <1818-2435-4445-5455-6465+ Unknow n Total Inter. VA0.00% 0.30%0.00% 1 EMS0.00%1.22% 4.88% 3.05%4.27%2.74%0.61%0.30%56 Law Enforcement0.00%2.13% 7.32% 4.27%5.18%3.66%0.91%0.30%78 Detention Center0.00%0.30%0.91%0.61%0.91%0.30% 0.00%11 Court System0.00%0.30%0.91%0.30%0.61%0.30%0.00% 8 Mental Health Tx0.00%0.61% 2.13% 1.22%1.52%0.91%0.30%0.00%22 Social & Human Services0.00%0.61% 2.44% 0.91%1.22%0.30%0.00%26 Community Supervision0.00% 1.83%1.52%2.13%1.52%0.30% 25 State's Attorney0.00% 2.44% 1.83% 2.44% 1.52%0.61%0.00%29 SEP/Staying Alive0.00% 0.61% 1.22%0.30% 0.00%10 Pharmacy0.00%0.30%0.00%0.30%0.00%0.30% 0.00%4 Drug Tx (Public and Private)0.00%0.61%3.66%3.35% 4.27% 1.52%0.91%0.61%49 Hospital0.00%0.30%0.91%0.30%0.61%0.00%0.61%0.00%9 328

10. AGENCY INTERACTION <1818-2425-3435-4445-5455-6465+ Unknow n Total Inter. VA0.00% 100.00%0.00% 100.00% EMS0.00%7.14% 28.57% 17.86%25.00%16.07%3.57%1.79%100.00% Law Enforcement0.00%8.97% 30.77% 17.95%21.79%15.38%3.85%1.28%100.00% Detention Center0.00%9.09%27.27%18.18%27.27%9.09% 0.00%100.00% Court System0.00%12.50% 37.50% 12.50%25.00%12.50%0.00% 100.00% Mental Health Tx0.00%9.09% 31.82% 18.18%22.73%13.64%4.55%0.00%100.00% Social & Human Services0.00%7.69% 30.77% 11.54%15.38%3.85%0.00%100.00% Community Supervision0.00% 24.00% 20.00% 28.00% 20.00%4.00% 100.00% State's Attorney0.00% 27.59%20.69%27.59%17.24%6.90%0.00%100.00% SEP/Staying Alive0.00% 20.00% 40.00% 10.00% 0.00%100.00% Pharmacy0.00%25.00%0.00%25.00%0.00%25.00% 0.00%100.00% Drug Tx (Public and Private)0.00%4.08% 24.49% 22.45% 28.57% 10.20%6.12%4.08%100.00% Hospital0.00%11.11% 33.33% 11.11%22.22%0.00%22.22%0.00%100.00%

11. DATA CHALLENGES AND LIMITATIONS  Dependent on entity, agency, or organization’s record keeping system and member attendance Time span of records Detail of medical history Veteran status/VA data Prescription data or PDMP Treatment data post-SMART Juvenile records Out of state records

12. NOTABLE TEAM MEMBER OBSERVATIONS Sheer amount of interaction with systems Especially the criminal justice system in BC Role of alcohol in overdose deaths Older drug users are at risk, with many co-occurring chronic health issues Care coordination in somatic health and after substance use disorder treatment Occurrence of trauma just before death (loss of a loved one, struggles with child custody, etc.)

13. TRENDS Deaths occurring in hotels and motels Recent release from jail; detoxification in jail system before release Hispanic population and LGBT History of intimate partner violence Poly-pharmacy Previous overdose Pain management noted in 7/86 (8%) pilot cases

14. IMPACTS/OUTCOMES ON PARTICIPATING AGENCIES Increase in number and improved the quality of the referral system Training of staff to use naloxone Educated and increased the awareness of staff of overdose related issues Promoting substance use disorder education and assessment at all levels of the organization Broader understanding of overdose in the community More direct outreach to families on overdose prevention and wraparound services by those that serve people at risk of overdose Changes to intake questionnaires to include questions about overdose history

15. OUTCOMES SYSTEM LEVEL Collaboration among partner agencies to strengthen outreach: BHSB and EMS Improvement to Treatment Referral Line in Baltimore City, collaboration between HCAM and BHSB Collaboration between local health department and EMS to follow up with overdose survivors Changes proposed to PDMP law to allow for data sharing with review teams

16. MOVING FORWARD  Continue the momentum with existing teams to build upon observations and potential recommendations  Capacity building of teams  Conference calls/collaborative learning for coordinators  Build team membership; improve attendence  Continue support and technical assistance to new teams, ensure understanding of program goals and confidentiality  Turn observations and recommendations into bigger action steps, further tracking those developments

17. CONTACT INFORMATION Erin Haas, MPH Maryland Department of Health and Mental Hygiene Behavioral Health Administration Overdose Prevention Office erin.haas@maryland.gov ​ Office: 410-402-8574 Cell: 443-827-0735