1. Opiate Use and Misuse in Oregon – Efforts from a Healthcare for the Homeless Clinic Rachel Solotaroff, MD, MCR Medical Director, Central City Concern May 2, 2013

2. Objectives Brief introduction of the opiate crisis in our community and in our clinic Our process as a clinic and a community in understanding and addressing this crisis Lessons learned

3. Disclosures No financial relationships to disclose I am a clinician and colleague; not an expert I am an incrementalist; not a trailblazer

4. BACKGROUND

5. Central City Concern CCC’s Mission: “To provide comprehensive solutions to ending homelessness and achieving self-sufficiency”  Continuum of integrated services:  Affordable housing  Addictions treatment  Mental health services  Recovery support  Employment services  Primary care

6. Old Town Clinic  Integrated into CCC in 2001  Healthcare for the Homeless Clinic  3500 patients; 15,000 PCP visits  35 percent uninsured  99 percent at 100% FPL or below  60-80 percent homeless  High prevalence of addiction & mental health disorders  Internal medicine; integrated BH, Pharmacy & OT  Strong complementary medicine department (ND, Acup)  Social medicine curriculum with OHSU Dept. of Medicine  Other robust academic partnerships (Pharm, PMHNP, OT)

7. OPIATE USE AND ABUSE IN OREGON – WHERE WE STOOD IN 2008

8. Deaths due to Drug Poisoning in Oregon Oregon Health Authority, Office of Disease Prevention and Epidemiology

9. Hospitalizations Oregon Health Authority, Office of Disease Prevention and Epidemiology

10. Who’s At Risk? Oregon Health Authority, Office of Disease Prevention and Epidemiology

11. Supportive Housing The Role of Methadone

12. Methadone: Grams Sold and Death Rate.

13. Factors Among Methadone Decedents 41% prescribed methadone; 30% no Rx Prescriptions: 43% pain; 26% methadone maintenance In 77%, abuse contributed to death 75% history of substance abuse 21% history of substance abuse treatment 52% history of mental illness Sample N=56 Oregon Health Authority, Office of Disease Prevention and Epidemiology

14. Pain Medication Misuse 2013: Oregon is THE highest state for nonmedical use of prescription pain relievers: –6.4% of all persons >12 years –7.4% of persons 12-17 years –15% of persons 18-25 years SAMHSA- 2008, 2013 National Survey on Drug Use and Health, state level data 2008: Oregon is 5th highest state for nonmedical use of prescription painkillers* 6.6% of persons >12 years 8.2% of persons 12-17 years 17.9% of persons 18-25 years – highest in any US state

15. Summary 53% of drug overdoses in Oregon associated with prescription opioids –Overall: 540% increase in since 1999 –Methadone: 1,500% increase in deaths since 1999 –33% of all drug-related deaths (licit and illicit) associated with methadone Oregon Health Authority, Office of Disease Prevention and Epidemiology

16. ADDRESSING THE EPIDEMIC

17. Back at Home… Providers: - Aware of lack of evidence and risks of opiates - Trying to grapple with patient expectation that “ a pill will make me pain free” - Lack of patient engagement with alternative modalities for pain management - Clinic sessions clogged with patients needing refills - Calls from the Medical Examiner when a death occurred Staff - Struggling with phone calls and walkins for refills - Managing behavioral issues when refills not granted as expected

18. Step 1: Establish Uniform Oversight and Prescribing Guidelines Controlled Substances Review Committee: Reviews all episodes of serious misuse or misconduct Reviews all requested new starts on chronic opiate therapy Provides guidance for complex pain management cases Early prescribing guidelines: When to refer to CSRC Prescribing to patient on methadone maintenance, in A&D treatment Process for new opiate starts Other contra-indicated substances Chelminski et al. BMC Health Services Research 2005, 5:3

19. Step 2: Integration of non-pharmacologic pain management and addiction Occupational Therapy/Group Visits Naturopathic Medicine/Acupuncture Education series for providers: Trigger Point Injections Musculoskeletal Exam Physiatry 101 Integrated Chronic Pain and Addictions Program – “Hot Sauce”: Led by CADC 12-week curriculum Focus on triggers, relapse prevention, alternative pain management

20. Patient, Staff and Provider Response Providers: –Relieved at no longer having to “go at it alone”; “makes being strict less personal”; “enables discussions around public health concerns” –Appreciative that we were no longer a “juice bar”; still feel patients need to embrace acceptance of their responsibility in pain management –Unclear of “net benefit”of Hot Sauce program Staff: –Perceived decreased burden of phone calls and walk-ins Patients: –Some felt groups were supportive and helpful; others felt they were a waste of time –Empathy with providers over having to “answer to some committee”

21. Step 3: Community-Wide Approach Multnomah County Health Department Guidelines 2011: –Instituted dosage ceiling limit on chronic opiate therapy –Established absolute contra-indications to COT –Established conditions for which chronic opiates could not be prescribed –Community Response: Get on the train, or get run over by the train Oregon Prescription Drug Monitoring Program, 2011 Death of Sam Barlow High School senior last December ruled an overdose 13-year-old Medford boy may have died from prescription drug overdose, police say

22. Our Current Controlled Substances Policy ABSOLUTE CONTRAINDICATIONS : Any history of diversion No functional improvement No complete workup for pain diagnosis Active substance abuse No non-pharmacological modalities tried, or unwillingness to try them Greater than 120mg daily of morphine equivalents (40mg methadone) Use of marijuana (licit or illicit)

23. Our Current Controlled Substances Policy RELATIVE CONTRAINDICATIONS (moving toward absolute*) : High opiate risk score No BH screening or undertreated BH condition History of suicide attempt Currently on methadone maintenance History of misuse/overuse Concurrent use of benzodiazepines *While we have made judicious exceptions in these areas, evidence and clinical experience are showing poor results

24. Strengthening Our Systems and Supports Level One Level Three Hot Sauce Weekly Acupuncture RENEW Monthly Group Visits with OT/PCP Behavioral Health Assessment or Impact Monthly “Activity Groups” Primary Care Only q 2-3 mo visits Chronic Pain Recovery Pyramid Level Two Low addiction risk: Good self-management Good support Good function/activity Low addiction risk BUT: Low self-management Low social supports Low function/activity High addiction risk: Brief relapse Early Recovery Minimal support Graduation Criteria: -- Level 3: completion of Hot Sauce -- Level 2: Progress toward goals Engaged in Behavioral health (if nec) Reduction in opiate dosage Risk Management -- UDS – q 3 months -- pill count – q 6 months -- ADR’s – q 3 months -- PDMP: annually

25. Income & Employment Volunteering, Training, Jobs CP Identified at Intake: -- ROI’s -- CP acknowledgemt -- BH Screen: ORT PHQ GAD-7 PTSD Screen OT Assess CSRC Reviews Data and recommends: -- No Controlled Substances + Care Plan Recs -- OR -- -- Controlled Substances + Level of Care + Care Plan Recs: Hot Sauce (Level 3) RENEW Provider Groups (Level 2) Primary Care Only (Level 1) Other recs such as BH, medication regiment, monitoring guidelines, etc. Behavioral Health Chronic Pain Recovery Program Road Map PCP Appt #1 PCP Appt #2 4 weeks If + BH Screen H&P, Record Review, UDS, OPDMP query

27. LESSONS LEARNED

28. Lessons Learned Absolute necessity and benefit of guidelines and review committee to which we all adhere “Cognitive dissonance” between population level data and the patient sitting in front of you While it’s great to have so many wellness resources, patient still needs to be engaged and receptive Addictions/Chronic Pain program such as “Hot Sauce” is innovative, but integration of suboxone has been the game-changer Need better focus on/understanding of intersection of trauma, addictions and chronic pain

29. THANK YOU!