Substance Use Disorder ResponseTeresa Koeller, MD, FASAM, Medical Director, Addiction Medicine

Dan Cole, CMPE, Assistant Vice President, Medical Specialties

2

St. Elizabeth Physicians• 518 Providers

• 372 Physicians

• 146 Advanced Practice Providers

• 1670 Associates (including providers)

• 40 Specialties & Services

• 117 Practices

• 30 Primary Care• 3 Hospitalist Programs

• 11 Heart & Vascular

• 6 OB/GYN

• 1 Express Care, 4 Urgent Care

• 3 states / 9 Counties

• All eligible PCPs designated Level 3 PCMH

• Participating in the CMMI Comprehensive Primary Care Initiative

• Serving over 315,000 patients

In 2017

• Nearly 1.5 million visits

• Over $320 million in revenue132

179

239

346 378 404437

487 511 518

0

100

200

300

400

500

600

December31, 2009

December31, 2010

December31, 2011

December31, 2012

December31, 2013

December31, 2014

December31, 2015

December31, 2016

December31, 2017

February1, 2018

Number of SEP Providers

40 Specialties & ServicesPrimary Care

• Family Medicine• Internal Medicine• Pediatrics• Internal Medicine/Pediatrics

• Occupational Medicine/Business Health• Hospitalists• Express Care• Urgent Care

Specialty Care

• Addiction Medicine• Bariatric Surgery• Behavioral Health• Breast Surgery• Cardiology• Colon & Rectal Surgery• Dermatology & Aesthetics• Electrophysiology• Emergency General

Surgery• Endocrinology• Gastroenterology

• General Surgery• Geriatrics• Holistic Health• Infectious Disease• Medical Oncology• Nephrology• Neurology• Obstetrics & Gynecology• Ophthalmology• Pain Management/Spine

• Physiatry• Podiatry • Pulmonology• Radiation Oncology• Rheumatology• Sleep Medicine• Surgical Oncology• Urogynecology• Urology• Vascular Surgery• Wound Care

2.16.18

3

4

Complications of Opioid Use

Societal Implications:

• Loss of job

• Broken families

• Homelessness

• Legal problems, jail, felonies

• Loss of potential income/under-education

• Illiteracy

• Lack of transportation

• Under Employment

• Societal & economic impact

Medical Complications:

• HIV

• Viral Hepatitis

• Syphilis

• Infectious Diseases

o Endocarditis

o Septic joints

o Cellulitis/abscess

• Hypogonadism

• Local tissue damage

• Neonatal Abstinence Syndrome

• Overdose/Death

Cost:

• HIV- $600,000 per patient NAS $66,000/treatment

• Heart Valve Replacement- $170,000 Hepatitis $90,000/treatment

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Northern Kentucky Heroin OverdosesSt. Elizabeth Emergency Departments

252447 545

745

1168

1584

2061

0

500

1000

1500

2000

2500

2011 2012 2013 2014 2015 2016 2017

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HIV and HEP C Risk In Northern Kentucky

Total HIV Cases:

34 2015

25 2016

37 2017

In 2017, a total

of 18 people

reported

injection drug

use among

their risk

factors,

compared to

only 5 in 2016

Northern Kentucky’s Hep C rates are 19 times greater than the average rate in the United States.

Of the 220 counties on the CDC’s “high risk” list for an HIV and HEP C outbreak, 25% are in Kentucky.

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Community education Prescription take-back boxes Drug abuse screenings

St. Elizabeth Response – Call to Action

Reduce the Supply

Establish a Regional Infrastructure

Advocate for Change

Reduce the Demand:

Prevent

Treat

Support

Protect (from Harm)

Strategies from Collective Plan St. Elizabeth Role Other Leadership Needed

Law enforcement for dealers Community watch

Patient education Provider education

Law enforcement Legislators

Continue leadership team Community education Impact analysis

Active role on leadership team Community education Submit data on impact

Heroin Impact Response Leadership Team

Heroin legislation Naloxone distribution Payment for services

Advocating for bills Narcan kit distribution SBIRT screenings

Legislators Cabinet for H&FS Medicaid MCOs

Community education SBIRT screenings Prescribing education and standards

Public health dept. Law enforcement Community pharmacies

Inpatient/detox Longer-term residential Medically-assisted Wraparound services Provider education

IP/IOP/OP services Supported CHNKY Hazelden 12-step Add IP bed capacity Increase suboxone prescribers (MDs) Bridge Clinic Vivitrol / rapid detox Increase residential treatment options Treatment options in jail

NorthKey Children’s Home of NKY Transitions Brighton Center Others

Community collaboration Develop 12-step program Employment opportunities Housing

Mental Health First Aid Resource guide Hazeldon program Navigation services (staffed)

Community/social service organizations Economic development/ housing

authorities NKY employers

Naloxone distribution Education to IDUs*, others Needle access

Narcan kits in EDs IDU education Naloxone MD order set Addiction clinic(s)

Legislators Cabinet for H&FS Public health dept.

* Injection Drug User (IDU)

ST. E

FOCUS

AREAS

8

Prevention

Treatment

Support

Restore/Replace

Protect

St. Elizabeth Response

9

SEP Partnered with Hazelden/Betty Ford

● Provide training and implementation of the

COR 12 Treatment Model.

● Develop centralized program to provide

medication assisted treatment in conjunction

with 12 Step Facilitated therapy to the patient

10

Medication Assisted Treatment

Goals

• “Harm Reduction”

• Decrease deaths, disease transmission

• Prevention or reduction of withdrawal symptoms

• Prevention or reduction of opioid craving

• Prevention of relapse to use of addictive opioids

• Restoration to or toward normalcy of any physiologic function disrupted by opioid use

Potential Outcomes

• Decreases impulsive behavior

• Helps to develop structure

• Decreases criminal activity

• Increases retention in treatment

• Increases engagement in socially productive roles

• Increases employability

• Decreases overall chaos in patient’s life/family

MAT can help improve overall function of patients and assist living a ‘normal’ and productive life.

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Medication Assisted Treatment Drug

Options

Methadone – full agonist

Buprenorphine – partial opiate agonist at the mu receptor. Slow dissociation from mu receptors, long duration of action. Milder withdrawal symptoms on discontinuation

Oral Naltrexone – opioid antagonist

Long-Acting Naltrexone Injection

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Three Medication Pathways

12 Step Facilitated Groups in Conjunction With…

Abstinence-based

Agonist Therapy

Naltrexone

13

First Pathway

Short Term Medications

Detox

Residential Treatment

Intensive Outpatient Treatment

Outpatient Therapy

Sober Living

Therapeutic Techniques

Cognitive Behavioral Therapy

Motivational enhancement therapy

Contingency Management

12 Step Facilitated Therapy

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Current StateSt. Elizabeth Physicians

Addiction Medicine and Recovery Program

• 1 FT Board Certified Addictionologist, 1 FT APRN and 8 PT Moonlighter MDs

• 3 Independently Licensed Clinical Counselors performing

o 12 Step Facilitated Groups

o 2 Pregnancy Groups, 10 Adult Groups

• Individual Counseling and Assessments

• Developed relationships with

o community behavioral health programs

o residential treatment and detox

• Created enterprise wide education programs on SBIRT

• Case Management

• Baby Steps Program for treatment of chemically dependent pregnant women

• ED Bridge Program

• Peer Support

• SUN Behavioral Health

• Provide Vivitrol treatment for clients of drug court

• Addiction Services Council Help Line

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Intensive Outpatient Treatment

Family Groups

Inpatient Evaluation and Treatment

Residential Treatment

Telemedicine

Ambulatory Detox

Develop Vivitrol program with jails

Methadone – OTP

Develop system-wide Peer Support

Future StateSt. Elizabeth Physicians

Addiction Medicine and Recovery Program

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Addiction is a chronic disease, not a moral failing—and one that must be addressed comprehensively across multiple service systems to be effective. We have set six community wide goals:

Moving our community from shock to programming and hope

Goal 1: To convene and connect across system to create realistic, sustainable solutions.

We need to better align our efforts. Although much has been accomplished, we need to dig deeper into the roots of addiction in order to prevent it from happening, or intervening early in the trajectory of use with effective treatment.

Goal 2: Prevent the adoption of unhealthy behaviors among 9-25 years old.

We need to address childhood adversity. We have learned that toxic stress or traumatic events in childhood are a significant risk factor for substance use disorders.

Goal 3: Decrease the infectious diseases associated with drug use.

We must have the tools to prevent the spread of diseases & increase access to health care services.

Goal 4: Decrease premature deaths due to drug overdoses.

We must broaden our reach to meet people where they are. The effectiveness of Quick Response Teams we will replicate that work into all areas where possible.

Goal 5: Provide evidence-based treatment specific to each person’s SUD to restore health.Health care providers must identify and manage people most at risk for addiction. Patients who call the NKY Helpline, and those who enter an emergency department for a SUD-related issue, must be appropriately and quickly assessed to be referred to the right treatment facility that is unique to their needs. These places are touch-points for screening, prevention services, and referral to treatment.

Goal 6: Provide comprehensive supports to people recovering from substance use disorders to restore

self-sufficiency and to quickly address recurrences.

Recovery support must be prioritized and coordinated. Recovery support has been disjointed and we

must make the alignment and coordination of community-based recovery services a priority.

17 Supporting Strategies: Advocacy, Communication, and Measuring Progress

Strong FamiliesResilient Children

Supportive Communities

Easy Access toBiopsychosocial

CareDisease

Management

Support for Re-entryPersonal

EmpowermentCareer

Development

NKY Hub for Transformative Action (NKY ASAP, Health Departments, HIRT, ODCP/SEH)

Outcomes

NKY Board for Transformative Leadership for Substance Use Disorders

Restoration and Recovery

Patient-Centered CarePositive Youth

DevelopmentHealth and Protection

Fewer OverdosesDeaths

Infectious Diseases

Impact Zone

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What can your community do now?

1. Acknowledge that your community has an issue with Substance Use Disorder

2. Support residential recovery programs

3. Support and help grow community educational programs

1. Town hall meetings

2. Awareness education on the complexity of the epidemic

4. Consider syringe access programs

5. Consideration of stigma and empathy education

6. Consider distributing Narcan to first responders and families of SUD population

7. Assisted people in recovery with

1. Employment opportunities

2. Transportation

3. Housing post residential treatment

4. Childcare assistance while in recovery

5. Life skills assistance

8. Support and collaborate with detention center and jails on educational programs

1. Nurturing families program

2. Vivitrol\Medication Assisted Treatment programs

3. Post release safe recovery assistance

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Speaker Information:

Dan Cole, CMPE

St. Elizabeth Physicians, Assistant Vice President, Medical Specialty 513-236-5536

Email: dan.cole@stelizabeth.com

Teresa Koeller, MD, FASAM

St. Elizabeth Physicians, Medical Director, Addiction Medicine and Recovery Center

Email: tkoeller@gmail.com

Presenters