1. Maryland Opioid Overdose Prevention Plan Components Department of Health and Mental Hygiene Maryland Opioid Overdose Prevention Planning Conference March 27, 2013

2. Enhanced Epidemiology Isabelle Horon, DrPH Director, Vital Statistics Administration Overdose Fatality Review & CDS Emergency Preparedness Lisa Hadley, MD Medical Director, Alcohol and Drug Abuse Administration & Mental Hygiene Administration Efforts to Reduce Rx Drug Abuse Michael Baier PDMP Coordinator, Alcohol and Drug Abuse Administration Local Plan Development Kathleen Rebbert-Franklin, LCSW-C Acting Director, Alcohol and Drug Abuse Administration

3. Enhanced Epidemiology to Assist Overdose Prevention Planning Activities Isabelle Horon, Dr.P.H. Director, Vital Statistics Administration Maryland Department of Health and Mental Hygiene Maryland Opioid Overdose Prevention Planning Conference March 27, 2013

4. Data are first, middle and last steps in any prevention initiative First step: – Accurately document the magnitude of the problem –Identify Factors associated with the problem Groups at increased risk Middle step: –Plan prevention programs –Allocate resources Last step: –Evaluate the effectiveness of the initiative

5. Secretary’s charge Develop a methodology for reporting on unintentional drug intoxication deaths occurring in Maryland Prepare a comprehensive report on trends in drug intoxication deaths at the county level Develop a methodology for monitoring drug intoxication deaths on an ongoi ng basis

6. http://dhmh.maryland.gov/vsa/Documents/Drug-and-Alcohol-Report-v5.pdf

7. Step 1. Identify sources of data OCME records –Scene examination –Toxicological analysis –Cause of death Death certificate data –Updated demographic data

8. Step 2. Review records provided by OCME Text of cause of death included: –Poisoning –Intoxication –Toxicity –Inhalation –Ingestion –Overdose –Exposure –Chemical –Use

9. Step 3. Identify drug-related intoxication deaths Reviewed OCME records to identify: –Recent ingestion or exposure to alcohol or another type of drug –Manner of death = accidental or undetermined

10. Identification of opioid-related deaths Heroin –“Heroin” mentioned in cause of death; or –Toxicology screen showed a positive result for 6-mam; or –Toxicology screen showed positive results for both morphine and quinine; or –Death identified as heroin-related through scene investigation –Associated with morphine; no other substance identified in cause of death Prescription drugs –Oxycodone, hydrocodone, methadone, fentanyl, tramadol, codeine, etc.

11. Data available Name Age Race/ethnicity Gender Place of death Place of residence Date of death Scene examination Manner of death Cause of death Toxicology results Updated demographic information from death records

12. Number of Heroin-Related Deaths Occurring in Maryland, 2007-2012.* *2012 data are preliminary

13. Number of Heroin-Related Deaths Occurring in Maryland by Age, 2007-2012.* *2012 data are preliminary

14. Number of Heroin-Related Deaths Occurring in Maryland by Race/Ethnicity, 2007-2012.* *2012 data are preliminary

15. Number of Heroin-Related Deaths Occurring in Maryland by Gender, 2007-2012.* *2012 data are preliminary

16. Number of Heroin-Related Deaths Occurring in Maryland by Age, 2007-2012.* *2012 data are preliminary

17. Number of Heroin-Related Deaths Occurring in Maryland by Race and Ethnicity, 2007-2012.* *2012 data are preliminary

18. Number of Heroin-Related Deaths Occurring in Maryland by Gender, 2007-2012.* *2012 data are preliminary

19. Number of Heroin-Related Deaths by Place of Occurrence, Maryland, 2007-2012.* *2012 data are preliminary

20. Number of Heroin-Related Deaths by Place of Occurrence, Maryland, 2007-2012.* *2012 data are preliminary

21. Summary Data available on all intoxication deaths –Alcohol and other drugs –2007 to present; updated monthly –Demographic data –Cause and manner of death –Toxicology results –Scene examination

22. For more information Isabelle Horon, Dr.P.H Maryland Vital Statistics Administration 410-764-3513 Isabelle.Horon@maryland.gov

23. Overdose Fatality Review (OFR) & CDS Emergency Preparedness Plan Lisa Hadley, MD Medical Director Alcohol and Drug Abuse Administration & Mental Hygiene Administration

24. Overdose Fatality Review (OFR)

25. OFR Purpose Improve access to overdose-related data from multiple sources at the state and local level Assist identification of factors that cause/are correlated with drug & alcohol overdose Improve interagency planning/coordination and support prevention strategy development & implementation

26. OFR Structure Model: State Child Fatality Review (H-G § 5-702) State Overdose Advisory Council (SOAC) Local Overdose Fatality Review Teams (LOFRT) SOAC & LOFRTs: “medical review committee” (H-O § 1-401) under DHMH Secretary/LHDs Confidential proceedings

27. State Overdose Advisory Council DHMH & other state agencies, healthcare providers, academic centers, LHDs, law enforcement Coordinate access to state data sources & disclosure to LOFRTs Review LOFRT reports & analyze statewide overdose trends Review jurisdictional/regional prevention plans & advise on implementation

28. Local Overdose Fatality Review Teams Multidisciplinary/multi-agency composition Suggested membership includes: LHD Behavioral health providers Emergency medicine/hospital Primary care & pain mgmt. Pharmacy Social services Law enforcement

29. Local Overdose Fatality Review Teams Pool & analyze overdose decedent data from state & local sources Determine overdose contributing factors Provide SOAC with standardized reports Make recommendations to state and local stakeholder organizations for systems change and improvements to prevention plans

30. OFR Pilot Implementation Identify pilot jurisdictions/regions ADAA provides pilot sites with template implementation documents Establish pilot LOFRTs LOFRTs provide recommendations to SOAC to create pathway for full implementation

31. Controlled Dangerous Substance (CDS) Emergency Preparedness Plan

32. Background 2011 : Eastern Shore pain management clinic with 1000-2000 patients closed abruptly due to physician license suspension Other possible examples of sudden disruption of CDS prescribing/dispensing: Sudden death or disability of prescriber Closure of methadone clinic Natural disaster

33. Background Ctd. Public health & safety fallout: Practice non-responsive to patient records requests Stigma inhibits transfer to new providers Patients at hospital emergency dept. and LHD Pharmacy robberies Ongoing problems with patient access to legitimate pain management

34. ADAA MOU w/ UMB School of Pharmacy Develop plan to respond to local public health emergencies created by sudden cessation of CDS prescribing/dispensing Create practitioner education/training tools Maintain network of trained practitioners on- call for emergency deployment Implement rapid response to screen & triage patients when incident occurs

35. Efforts to Address Rx Abuse: Prescription Drug Monitoring Program, Controlled Dangerous Substance Integration Unit & Medicaid “Lock-In” Michael Baier PDMP Coordinator Alcohol and Drug Abuse Administration

37. Prescription Drug Monitoring Program (PDMP)

38. PDMP Public Health Objectives Give healthcare providers real-time access to patient controlled substance Rx history at the point-of-care to: Identify “doctor shopping,” indicating Rx abuse or diversion Intervene with Rx abusing patients => treatment referral Increase provider awareness of and ability to deal with substance use disorders Improve provider ability to manage pain effectively Increase confidence in prescribing decisions

39. What is the PDMP? Electronic monitoring of prescribing and dispensing of Schedules II-V CDS (including opioids, benzos, psycho-stimulants, etc.) Create comprehensive CDS Rx database Make Rx data available to:  Prescribers  Dispensers  Health Professional Licensing Boards  Law Enforcement  Units of DHMH (OCME, Medicaid, OIG, OHCQ)  Researchers  Patients

41. How Will the PDMP Work? For each CDS Rx dispensed, dispenser (including pharmacies & dispensing practitioners) must report identifying information for: Patient for whom drug is prescribed (name, gender, address, DOB, etc.) Prescriber (DEA #) Dispenser (DEA #) Drug (NDC, quantity, dose amount, days supply, etc.)

42. Who Can Request Data? Prescribers (in connection with care of patient) Dispensers (in connection with dispensing request) Law Enforcement (subpoena required) Licensing Boards (administrative subpoena required) Patient (may include parent/guardian for minors) Units of DHMH (existing investigation required) Other states’ PDMPs (if authorized and employing confidentiality, security and access standards at least as stringent as MD’s PDMP) Researchers (de-identified data only)

43. MD PDMP Facts Legislation, 2011: Health-General § 21-2A Regulations, 2013: COMAR 10.47.07 Under DHMH, housed in ADAA Program IT: Chesapeake Regional Information System for our Patients (CRISP)

44. CRISP Background 2007: designated statewide health information exchange (HIE) Received $20+ million in state and federal funding to implement HIE Current connectivity with all 46 acute care hospitals in state

45. Benefits of PDMP/HIE Integration Prescribers: Single point of access to PDMP data and patient info available through HIE for clinical end users Single set of log-in credentials for PDMP & HIE Everyone: Improved accuracy of unique patient identification Synergy in recruiting, registering & training users Sustainability: well-established public-private partnership

46. Implementation Timeline CRISP RFP: 12/2012 – 3/2013 Implementation begins: April Dispenser reporting begins: est. July – August Non-clinical user registration: begins August – Sept. Clinical user registration (thru HIE): begins Oct. – Nov.

47. Controlled Dangerous Substance Integration Unit (CDSIU)

48. CDSIU Design DHMH “fusion center” for info on CDS prescribing, dispensing & use Personnel from DHMH agencies & licensing boards that conduct investigations Established as a “medical review committee” by DHMH Secretary

49. CDSIU Goals Break down barriers to information sharing between DHMH agencies and licensing boards Replace ad hoc cooperation on investigations & enforcement/disciplinary actions with systematic coordination & planning Early identification/intervention problematic CDS Rx Coordinate with local health departments & treatment providers to minimize public health impact of regulatory/enforcement actions

50. CDSIU Membership Dep. Secs. Public Health & Behavioral Health DHMH Chief Medical Officer Alcohol & Drug Abuse Administration Division of Drug Control/Laboratories Administration Maryland Medicaid Office of the Inspector General Office of the Attorney General Office of the Chief Medical Examiner Office of Health Care Quality Boards of Physicians, Pharmacy, Nursing, Dentistry

51. Medicaid “Lock-In” Corrective Managed Care (CMC) Program

52. CMC Overview Prevent misuse of Medical Assistance pharmacy benefit “Lock-in” enrollee to preselected practitioners and pharmacy for non-emergency care Focus on opioid Rx received from multiple prescribers and dispensers indicating drug abuse or diversion

53. Medicaid Fee-For-Service CMC Enrollee screening criteria: 1.Opioid utilization in patients with diagnosis of SUD history 2.Long-term use of short acting opioids with no utilization of a long-acting agent 3.Utilization of methadone 4.Overutilization of hydrocodone suspension (Tussionex) 5.Utilization of any narcotics concurrently with Suboxone 6.Recipients with at least a 120-day supply of any opioid within the most recent 90-day time period based on an evaluation of the day supply field 7.Overutilization of opioids based on doses per day

54. MCO Enrollee Screening Criteria Priority Partners & Amerigroup: 1.≥ 6 opiate prescriptions and ≥ 3 different providers in a one month period 2.Two or more opiate prescriptions each for at least 360 doses in a 3 month period 3.Discharged by provider for suspected opiate Rx fraud UnitedHealthcare: 1.Supply overlap of ≥ 45 days for ≥ 2 different oral extended- release or long-acting opioid Rx 2.Sees ≥ 4 prescribers for Rx for same opioid 3.Sees ≥ 4 pharmacies for Rx for same opioid

55. Next Steps Create standardized lock-in criteria for FFS & MCOs Improve treatment referral process for enrollees demonstrating possible Rx drug- related SUDs Use PDMP data to improve screening and compliance monitoring

56. Local Overdose Prevention Plan Development Kathleen Rebbert-Franklin, LCSW-C Acting Director Alcohol and Drug Abuse Administration

57. Overview LHDs lead development of plan to prevent drug and alcohol overdoses Multiple jurisdictions may work together to develop regional plans Identify contours of local problem (fatal and non-fatal overdose) and conduct needs assessment Should include input from/coordination with multiple stakeholders (LHD, treatment providers, hospital, law enforcement, social services, community, etc.)

58. Required Components Data review and analysis Clinical community education: incl. somatic & behavioral health treatment providers, emergency medicine Strategy for outreach to high risk individuals: identification, intervention, referral Performance metrics

59. Timeline Death data disclosure to LHDs and OFR pilot site identification: April Draft local plans due April 30 th Final local plans due June 30 th State Overdose Advisory Council review of local plans: July

60. Thanks for your attention QUESTIONS?