Maryland Opioid Overdose

Prevention Plan Components

Department of Health and Mental HygieneMaryland Opioid Overdose Prevention

Planning ConferenceMarch 27, 2013

Enhanced EpidemiologyIsabelle Horon, DrPH

Director, Vital Statistics Administration

Overdose Fatality Review & CDS Emergency PreparednessLisa Hadley, MD

Medical Director, Alcohol and Drug Abuse Administration & Mental Hygiene Administration

Efforts to Reduce Rx Drug AbuseMichael Baier

PDMP Coordinator, Alcohol and Drug Abuse Administration

Local Plan DevelopmentKathleen Rebbert-Franklin, LCSW-C

Acting Director, Alcohol and Drug Abuse Administration

Enhanced Epidemiology to Assist Overdose Prevention

Planning Activities

Isabelle Horon, Dr.P.H.Director, Vital Statistics Administration

Maryland Department of Health andMental Hygiene

Maryland Opioid Overdose Prevention Planning ConferenceMarch 27, 2013

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

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 ongoing basis

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

Step 1. Identify sources of data• OCME records

– Scene examination – Toxicological analysis– Cause of death

• Death certificate data– Updated demographic data

Step 2. Review records provided by OCME

• Text of cause of death included:– Poisoning– Intoxication– Toxicity– Inhalation– Ingestion– Overdose– Exposure– Chemical– Use

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

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.

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

Number of Heroin-Related Deaths Occurring in Maryland, 2007-2012.*

*2012 data are preliminary

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

*2012 data are preliminary

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

*2012 data are preliminary

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

*2012 data are preliminary

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

*2012 data are preliminary

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

*2012 data are preliminary

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

*2012 data are preliminary

Number of Heroin-Related Deaths by Place of Occurrence, Maryland, 2007-2012.*

*2012 data are preliminary

Number of Heroin-Related Deaths by Place of Occurrence, Maryland, 2007-2012.*

*2012 data are preliminary

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

For more information

Isabelle Horon, Dr.P.HMaryland Vital Statistics Administration

410-764-3513Isabelle.Horon@maryland.gov

Overdose Fatality Review (OFR) & CDS

Emergency Preparedness PlanLisa Hadley, MD

Medical DirectorAlcohol and Drug Abuse Administration &

Mental Hygiene Administration

Overdose Fatality Review (OFR)

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

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

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

Local Overdose Fatality Review Teams

Multidisciplinary/multi-agency compositionSuggested membership includes: •LHD•Behavioral health providers•Emergency medicine/hospital•Primary care & pain mgmt.•Pharmacy•Social services•Law enforcement

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

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

Controlled Dangerous Substance (CDS)

Emergency Preparedness Plan

Background2011: Eastern Shore pain management clinic with 1000-2000 patients closed abruptly due to physician license suspensionOther possible examples of sudden disruption of CDS prescribing/dispensing:•Sudden death or disability of prescriber•Closure of methadone clinic•Natural disaster

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

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

Efforts to Address Rx Abuse:

Prescription Drug Monitoring Program,

Controlled Dangerous Substance Integration Unit & Medicaid “Lock-In”Michael Baier

PDMP CoordinatorAlcohol and Drug Abuse Administration

Prescription Drug Monitoring Program

(PDMP)

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

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:

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.)

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)

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)

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

Benefits of PDMP/HIE IntegrationPrescribers:

• 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

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.

Controlled Dangerous Substance Integration

Unit (CDSIU)

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

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

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

Medicaid “Lock-In” Corrective Managed Care

(CMC) Program

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

Medicaid Fee-For-Service CMC

Enrollee screening criteria:1. Opioid utilization in patients with diagnosis of SUD

history2. Long-term use of short acting opioids with no

utilization of a long-acting agent3. Utilization of methadone4. Overutilization of hydrocodone suspension

(Tussionex)5. Utilization of any narcotics concurrently with

Suboxone6. 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

MCO Enrollee Screening CriteriaPriority 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 fraudUnitedHealthcare:

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 opioid3. Sees ≥ 4 pharmacies for Rx for same opioid

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

Local Overdose Prevention Plan

DevelopmentKathleen Rebbert-Franklin, LCSW-C

Acting DirectorAlcohol and Drug Abuse

Administration

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.)

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

Timeline• Death data disclosure to LHDs

and OFR pilot site identification: April

• Draft local plans due April 30th

• Final local plans due June 30th

• State Overdose Advisory Council review of local plans: July

Thanks for your attentionQUESTIONS?