Post on 13-Jan-2016
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Opiate Use and Misuse in Oregon – Efforts from a Healthcare for the Homeless Clinic
Rachel Solotaroff, MD, MCRMedical Director, Central City ConcernMay 2, 2013
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
Disclosures
No financial relationships to disclose
I am a clinician and colleague; not an expert
I am an incrementalist; not a trailblazer
BACKGROUND
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
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)
OPIATE USE AND ABUSE IN OREGON – WHERE WE STOOD IN 2008
Deaths due to Drug Poisoning in Oregon
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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Drug poisoning mortality: rate and frequency by year and select drug type, Oregon, 1999-2008
Number of cocaine deaths
Number of heroin deaths
Number of prescription opioid deaths
Rate of drug poisoning
Oregon Public Health Division- Injury Prevention Program
*2008 mortality data are preliminary; drug death categories are not necessarily mutually exclusive- deaths may involve multiple drugs. Includes unintentional and undetermined drug poisonings. Data source: Oregon Center for Health Statistics mortality data file.
Oregon Health Authority, Office of Disease Prevention and Epidemiology
Hospitalizations
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1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
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Unintentional poisoning hospitalization- rate and frequency by drug category and year, Oregon 1997-2007
Other drugs (44 categories combined)
Opioid analgesics (+ methadone)
Rate of unintentional poisoning
Oregon Public Health Division- Injury Prevention Program
Data source: Oregon Hospital Discharge Index
Oregon Health Authority, Office of Disease Prevention and Epidemiology
Who’s At Risk?
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18.7
26.5
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1.46 0.510
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Perc
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Age distribution of prescription opioid deaths, Oregon, 1999-2009
Oregon Public Health Division- Injury Prevention Program
Oregon Health Authority, Office of Disease Prevention and Epidemiology
Supportive Housing
The Role of Methadone
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
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Drug poisoning mortality: the role of methadone, Oregon, 1999-2008
All drug and medication-related deaths combinedAll prescription opioid-related deaths combinedMethadone-related deaths
2008 data are preliminary. Categories are not mutually exclusive- many deaths sumultaneously involve several types of drugs. Includes only deaths with an X40-X44 & Y10-Y14 ICD-10 code for underlying cause of death (unintentional and undetermined intent).
Oregon Injury Prevention ProgramPublic Health Division
Methadone: Grams Sold and Death Rate.
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1999 2000 2001 2002 2003 2004 2005 2006 Rat
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Note: grams sold on left axis, death rate on right axis
Retail distribution of methadone in Oregon and poisoning mortality rate asociated with methadone in Oregon, 1999-2006
Grams sold/100,000 population
Methadone death rate
Sources: US Dept. of Justice, Drug Enforcement Administration, Of f ice of Diversion Control, Automation of Reports and Consolidated Orders System (ARCOS); Oregon Center for Health Statistics mortality data f iles. Includes unintetnional and undetermined intent deaths.
Oregon Public Health Division- Injury Prevention Program
Factors Among Methadone Decedents
41% prescribed methadone; 30% no RxPrescriptions: 43% pain; 26% methadone
maintenanceIn 77%, abuse contributed to death75% history of substance abuse21% history of substance abuse treatment52% history of mental illness
Sample N=56Oregon Health Authority, Office of Disease Prevention and Epidemiology
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 years8.2% of persons 12-17 years17.9% of persons 18-25 years – highest in any US state
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
ADDRESSING THE EPIDEMIC
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
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
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
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”
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
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)
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
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
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
LESSONS LEARNED
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
THANK YOU!