Jeffrey Coady, Psy.D., ABPP CAPT, United States Public Health Service

1. Jeffrey Coady, Psy.D., ABPP CAPT, United States Public Health Service SAMHSA Regional Administrator (5) Advancing Prevention, Treatment, and Recovery in Opioids and other Substance Use Disorders (SUD) • The Triple Threat: HIV, Hepatitis C and Opioids • June 25, 2019 Chicago, IL

2. Today’s Presentation • Addictions • What does the existing data tell us about addictions, HCV, and HIV • What actions can we take to advance prevention, treatment, and recovery? • What resources are available to implement the actions? • What have we not discussed?

3. Your Brain on Drugs in the 1980’s NIDA

4. Age at tobacco, alcohol, and cannabis dependence per DSM IV Addiction Is a Developmental Disease that starts in Adolescence and Childhood 1.8% 1.8% TOBACCO CANNABIS 1.6% 1.6% ALCOHOL 1.4% 1.4% 1.2% 1.2% 1.0% 1.0% % in each age group who develop first-time dependence 0.8% 0.8% 0.6% 0.6% 0.4% 0.4% 0.2% 0.2% 0.0% 0.0% 5 10 15 21 25 30 35 40 45 50 55 60 65 5 10 15 21 25 30 35 40 45 50 55 60 65 Age National Epidemiologic Survey on Alcohol and Related Conditions, 2003.

5. Hipp NAcc VP Amyg Addiction Dysregulates Brain Circuits EXECUTIVE FUNCTION PFC ACG INHIBITORY CONTROL OFC SCC REWARD/ PLEASURE LEARNING/ MEMORY MOTIVATION/ DRIVE Maureen Boyle, Ph.D., NIDA

6. Dopamine D2 Receptors are Decreased by Addiction Cocaine Meth DA D2 Receptor Availability Alcohol Heroin Control Addicted

7. Low D2 Receptors Lead to Decreased Frontal Activity control cocaine use disorder Striatum D2 receptors Volkow et al., AJP 158(3):377-382, 2001. Source: Maureen Boyle, Ph.D., NIDA

8. Control Control frontal cortex STOP Saliency Saliency Drive Drive Drive frontal cortex Saliency NAc GO Memory Memory Amygdala Addicted Brain Non-AddictedBrain Maureen Boyle, Ph.D., NIDA

9. Mental and Substance Use Disorders in America: NSDUH 2017 PAST YEAR, 2017, 18+ Among those with a substance use disorder approximately: • 3 IN 8 (36.4%) struggled with illicit drugs • 3 IN 4 (75.2%) struggled with alcohol use • 1 IN 9 (11.5%) struggled with illicit drugs and alcohol Among those with a mental illness approximately: • 1 IN 4 (24.0%) had a serious mental illness 3.4% (8.5 MILLION) 18+ HAD BOTH substance use disorder and a mental illness 7.6% (18.7 MILLION) People aged 18 or older had a substance use disorder 18.9% (46.6 MILLION) People aged 18 or older had a mental illness 56.8 million adults are affected either by a mental disorder or substance use disorder. .4% .3% .2%

10. Nonmedical Use of Prescription Opioids Significant Risk Factor for Heroin Use 3 out of 4 people who used heroin in the past year misused prescription opioids first 7 out of 10 people who used heroin in the past year also misused prescription opioids in the past year 2017: 2.1 million with opioid use disorder Source: Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. (2013). Slide credit – Grant Baldwin, CDC

11. Sources of Where Pain Relievers Were Obtained for Most Recent Misuse Among People Who Misused Prescription Pain Relievers PAST YEAR, 2017, 12+

12. Opioid Related Deaths

13. What Does the Existing Data Tell Us? • Only 55% of those who need treatment for heroin use disorder and 21% of those who need treatment for prescription pain reliever use disorder get treatment. • Heroin and illicit opioid pills contaminated by fentanyl and other potent opioids account for the majority of overdose deaths • Prescription Opioid relievers account for most of the opioid misuse/use disorders that exist in the U.S. • Overprescribing and lack of public and patient education/awareness of the addictive potential and danger of prescription opioid misuse, are a major part of the problem. • Additionally, stigma, lack of resources, lack of providers and lack of evidence-based treatment availability/community recovery supports continue to be contributing factors of the opioid crisis.

14. Substance Use and the LGBT Community • 40 percent of LGB adults had used illicit drugs in the past year. Comparatively, 18 percent of all adults had used illicit drugs in the past year • In the past year, 10.5 percent of LGB adults had misused prescription pain relievers compared to 4.5 percent of all adults who had misused prescription pain relievers. • In the past year, 0.9 percent of LGB adults used heroin compared to 0.4 percent of all adults who used heroin.

15. Despite Great Need Treatment Gaps Remain Vast PAST YEAR, 2017 • From 2004 to 2015, the number of buprenorphine visits rose from 0.04% to 0.36% of all ambulatory visits, representing 13.4 million visits between 2012 and 2015. • Buprenorphine prescription was received at considerably more visits by white patients than patients of other races/ethnicities • Black patients had statistically significantly lower odds of receiving buprenorphine prescription at their visits Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. Published online May 08, 2019. doi:10.1001/jamapsychiatry.2019.0876

16. What does the existing data tell us about HCV and drug use?

17. Hepatitis C and Injection Drug Use

18. Hepatitis C and Injection Drug Use • With increased rates of opioid injection, there have also been increases in acute Hepatitis C infection related hospital admissions across the country. • Rates of opioid injection—especially injection of prescription opioid pain relievers, as well as heroin—and acute hepatitis C virus infections increased most dramatically from 2004 to 2014 among younger Americans (ages 18-39). • There were also sharp increases among whites and among women. • Increases in prescription opioid sales, opioid overdose deaths, and HCV are indications for incident of HIV.

19. Drug Overdoses and Hepatitis C: Interconnected Epidemics Drug Overdose Death Rates Reported New HCV Infections SOURCE: CDC/NCHS Data Visualization Gallery 2015 SOURCE: CDC National NotifiableDisease Surveillance System 2013-14

20. What does the existing data tell us about HIV and drug use?

21. Injection Drug Use-Associated HIV is Increasing Increase of 4% in 2015

22. HIV and Substance Use Disorders • According to CDC in 2016, persons who injected drugs represented “9% (3,425) of the 39,782 diagnoses of HIV in the United States in 2016 (2,224 cases were attributed to injection drug use and 1,201 to male-to-male sexual contact and injection drug use).” • Highlighted by recent outbreaks such as Scott County (Indiana). From November 2014-November 2015, 181 cases of HIV with about 87 percent using opioids (oxymorphone). • Links to hepatitis and other communicable diseases as well as HIV • Often co-occurring mental health conditions

23. Opioid, HIV, and HCV Epidemics Ignite in a Rural Indiana Community • 223 people with HIV • 90% have HCV coinfection • 5% adults with HIV (population 3,143) • Over $100 million in lifetime medical costs • Outbreak stopped Credit: Tyler Stewart / Associated Press

24. What are the solutions?

25. HHS Opioid Strategy HHS Five-Point Opioid Strategy 1 2 3 4 5

26. Strategies to Address the Opioid Epidemic Workforce Community Prevention Crisis Services Recovery Support Clinical Practice • Strategic Planning • Community & Provider Education • Harm Reduction • Medication Disposal • Access to Health Care • Safe & Affordable Housing • Education & Employment • Social & Community Connections • Data 2000 Waiver (MD/PA/APRN) • Clinician Support & Continuing Education • Recruitment & Retention Plans • Integrated Care Competencies • Peer Recovery • CDC Pain Management Guidelines • Screening & Assessment • Medication Assisted Treatment • SUD Levels of Treatment • PDMP • Tele-Health • Naloxone distribution & education: 1st responders, patients, family • ER overdose education (MAT initiation) • Detoxification • Link ER/Detox to treatment

27. Comprehensive Community Action • Identify areas of need, mobilize community including health and law enforcement sectors • • Comprehensive syringe service programs (SSPs) • • Substance use treatment; naloxone • • HIV and hepatitis testing, link to treatment • • Sterile syringes • • SSPs prevent HIV and HCV infection and do not increase drug use or crime • • People who used SSP 5 times more likely to enter drug treatment and 3 times more likely to stop injecting • • Cost saving HOI Commonwealth Dept Health Aging, 2002; MacArthur G; BMJ 2012. Aspinall E J et al. Int J. Epidemiology, 2014; Hagan J Sub Abuse Treatment 2000; Harm reduction coalition

28. Leveraging Existing Services • Community health centers, HIV and STD programs, and clinical services in all 50 states • • Screen and refer people to substance use treatment • • Test and treat for viral hepatitis, HIV • • Viral hepatitis programs supported in 46 states • • Enhanced surveillance data from 14 states that represent >70% of the HBV/HCV cases in US • • Use acute HCV infections as indicator of need for rapid community action Credit: Tyler Stewart / Associated Press

29. MAT: Standard of Care for Opioid Use Disorders • Medicated-Assisted Treatment (MAT) is the use of FDA- approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. • MAT for Opioid Use Disorder • MAT for Alcohol Use Disorder • MAT for Smoking

30. MAT: Standard of Care for Opioid Use Disorders • MAT Treatment • Methadone • Buprenorphine/Naloxone • Qualifyingphysicianscantreatup to30, 100or 275 patients • QualifyingNP’sandPA’s can treat up to30 or 100 Suboxone • Injectable naltrexone • Medication treatment while in DOC; referral to ongoing care for OUD on release • Comparison of opioid overdose deaths first 6 months of 2016 vs. 2017: 61% reduction in opioid-associated overdose deaths upon release from incarceration • Overall 12% reduction in opioid overdose deaths in Rhode Island (2017) • Importance of MAT and warm handoff to outpatient providers Green TC, et al. JAMA Psychiatry, 2018

31. Efficacy of Medications • After buprenorphine became available in Baltimore, heroin overdose deaths decreased by 37%. • Source: Maureen Boyle, Ph.D., NIDA

32. Benefits of MAT • Reduces all cause mortality • Reduces HIV risk • Improves adherence to medical treatment • Improves social function • Decreases criminal behaviors • Decreases drug use

33. Benefits of MAT: Suicide Prevention • Suicide is the leading cause of death among people with substance use disorders (SUDs). • Compared with the general population, people treated for alcohol abuse or dependence are at about a 10x greater risk for suicide. (Wilcox, et al., 2004) • Those who inject drugs are at about a 14x greater risk for suicide. (Wilcox, et al., 2004) • The number of substances used seems more predictive of suicide than the types. BF headline, increased size from 32 to 44 point; capitalized and added break after “Between”; increased size of body text from 26 to 32 point

34. Expertise

35. Adverse Childhood Experiences

36. Trauma Informed Care • SAMHSA’s Concept of Trauma 3-E’s : Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and/or emotionally harmful or threatening and that has lasting adverse effectson the individual’s functioning and mental, physical, social, emotional, and/or spiritual well-being • Adoption of principles and practices that promote a culture of safety, empowerment, and healing. • Based on what we know about the prevalence and impact of trauma, it is necessary to ensure widespread adoption of trauma-informed care. • Bi directional relationship with addictions

37. SBIRT Learning Tool – Brief Intervention Steps

38. Motivational Interviewing Ambivalence Change Talk Sustain Talk “Client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Miller & Rollnick, 1992

39. Recovery Oriented System of Care Arthur Evans

40. Creating and Reinforcing Recovery Capital Essential Ingredients for Sustained Recovery: • Safe and affordable place to live • Steady employment and job readiness • Education and vocational skills • Life and recovery skills • Health and wellness • Recovery support networks • Sense of belonging and purpose • Community and civic engagement

41. Creating and Reinforcing Recovery Capital Often, a Need to Address: • Legal issues • Expunging criminal records • Financial status: debt, taxes, budgeting, etc. • Restoring revoked licenses: professional, business, driver’s • Regaining custody of children • Developing relationship and parenting skills • Developing recovery support networks and community connections

42. Resources

43. Resources (hhs.gov/opioid)

44. SAMHSA: Technical Assistance and Training Programs in a Variety of Formats Evidence-Based Practice Repository in NMHSUPL National Technical Assistance/Training Centers: State Targeted Response to Opioids, Providers’ Clinical Support System for Medication Assisted Treatment, Clinical Support System for Serious Mental Illness, National Child Traumatic Stress Network, National Center on Substance Abuse and Child Welfare, Center for Integrated Health Services, Veterans, GAINS (Criminal Justice), Disaster, Social Inclusion/Public Education, SOAR, Suicide Prevention, Eating Disorders, Privacy Regional Substance Abuse Prevention, Addiction, Mental Health/School Based Services Collaborating Technology Transfer Centers Combined Efforts at the Regional, State, and Local Levels Oriented to All Health Professionals Region 6 Region 8 Region 9 Region 10 Region 3 Region 2 Region 1 Region 7 Region 4 Region 5 National Hispanic/Latino TTC National American Indian/Alaska Native TTC

45. Providers Clinical Support System Training • Provider’s Clinical Support System – Medication Assisted Treatment (PCSS-MAT) provides waiver trainings, online CME courses, and no-cost clinical coaching/mentoring to support evidence-based treatment of substance use disorders and co-occurring mental disorders. https://pcssnow.org/medication-assisted-treatment/

46. National Recovery Month https://www.recoverymonth.gov/

47. Prescription Drug Take Back Day: October 26, 2019 https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html

48. THANK YOU FOR WHAT YOU DO IN YOUR COMMUNITY TO HELP OTHERS Jeffrey Coady, Psy.D., ABPP CAPT, United States Public Health Service SAMHSA Regional Administrator Jeffrey.Coady@samhsa.hhs.gov