South Central PA Opioid Awareness Coalition Forum

1. South Central PA Opioid Awareness Coalition ForumSeptember 15, 2017 SIGN UP TO TAKE A TWO QUESTION POLL BEFORE THE EVENT BEGINS!! Text: opioid2017 TO 22333or go to pollev.com/opioid2017

4. Framing the Issue: Robert G. Shipp III, RNVice President Population Health Strategies

5. Framing the IssueAudience Participation Question 1 What word comes to mind when you hear opioids? Question 2 How best can the opioid crisis be addressed? • Greater community education • Easier access to addiction specialists and support • Increased legislation • Clearer prescription guidelines

6. Framing the Issue: Pennsylvania’s Epidemic • 4,642 drug overdose deaths in PA (2016) • 37% increase from 2015 • South Central: More than 450 deaths in our seven counties CountyOverdose death rate Adams: 27.6 Cumberland: 24.6 Dauphin: 31.3 Franklin: 26.1 Lancaster: 22.3 Lebanon: 12.0 York: 29.2 13 deaths per day in Pennsylvania in 2016. Expected to be more in 2017 Source: DEA, 2017 PA has one of the highest state average rates in the country

7. Most Frequently Reported Overdose Deaths- 2016 In our region: #1 Heroin #2 Fentanyl 6 of our 7 counties are above the U.S. death rate Source: DEA, 2017

8. Framing the Issue: What is being done Nationally — • Congress passed opioid legislation • Comprehensive Addiction and Recovery Act (CARA) • 21st Century Cures Act • Pennsylvania received $26 million in funding • President’s Commission on Combating Drug Addiction and the Opioid Crisis • President Trump proclaimed September 2017 as National Alcohol and Drug Addiction Recovery Month • Congressman Tom Marino nominated as Drug Czar Pennsylvania — • Established legislative and executive task forces • Additional Centers of Excellence • Passed a series of bills addressing this epidemic. Additional package introduced this session • Began distributing drug disposal bags in hardest hit counties • Announced standing order for Naloxone at any pharmacy • Released medication prescription guidelines These interventions help, but there is still more we can do…

9. Framing the Issue: Why are we here today • Understand the issue(s) • Reduce the stigma • Unify in messaging • Coordinate efforts “As trusted healthcare clinicians, it’s our duty to work together to share best practices, increase awareness, promote education, and improve treatment, through a unified approach to combating this epidemic”

10. Framing the Issue:Resources Visit the South Central PA Opioid Awareness Coalition websitefor additional information www.opioidaware.org

12. Primary Care Chris Echterling, M.D.

13. Primary Care • Prescriber education (ex. CDC Guidelines) • Opioids are not first line treatment for chronic pain • Opioid agreements reflecting informed shared care plan • Opioid risks, securing medicine and disposal • Dependency vs Addiction • Monitoring for safety – urine drug tests • Prescription Drug Monitoring Program (PDMP)

14. Scope of the problem 76 • suffer from chronic pain, more than diabetes, CAD and cancer combined million

16. Primary Care CDC Guidelines • Opioids are not first line treatment for chronic pain • Focus on function, not pain • Shorter supplies for acute pain – then re-evaluate • Monitoring for safety (urine drug tests), NOT accusing • Prescription Drug Monitoring Program (PDMP) • Higher doses and drug interactions

17. Primary Care Preventing diversion • Secure your meds – don’t temp those who are struggling • Dispose of left over meds – take back boxes or trash • Dependency vs Addiction

19. Primary Care • Naloxone (Narcan) • Prevention • Survive accidental overdose (ill, child, confused) • Cannot recover if you are dead (“deadliest times” for those with substance use disorder) • Guidelines • Higher dose of opioids • History of addiction/overdose • You or a family member

20. Medically Assisted Treatment Adam Lake, M.D.

21. Medically Assisted Treatment • Addiction is a disease • The drug is not the problem Treatment works MAT works the best

22. Medically Assisted Treatment • MAT = medication + therapy • No clear best type of or intensity of therapy (1-4) • Several options for the medication • Sources: • Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. Journal of Addiction Medicine. 2016;10(2):91-101. doi:10.1097/ADM.0000000000000193. • Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD004147. DOI: 10.1002/14651858.CD004147.pub4. • Moore BA, Fiellin DA, Cutter CJ, Buono FD, Barry DT, Fiellin LE, O'Connor PG, Schottenfeld RS. Cognitive Behavioral Therapy Improves Treatment Outcomes for Prescription Opioid Users in Primary Care Buprenorphine Treatment. J Subst Abuse Treat. 2016 Dec;71:54-57. doi: 10.1016/j.jsat.2016.08.016. Epub 2016 Sep 2. • Torchalla, I., Nosen, L., Rostam, H., & Allen, P. (2012). Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: A systematic review and meta-analysis. Journal of substance abuse treatment, 42(1), 65-77.

23. Medically Assisted Treatment Why use any medication? 3/20 died from overdoses Kakko J, Svanborg KD, Kreek MJ, Heilig M. (2003) 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet, 361:662-668. Data from Sordo, et al. BMJ 2017;357:j1550. Visualization from plot.ly

24. Medically Assisted Treatment • Methadone • Buprenorphine (tablet, film, implant) • Naltrexone (oral and long-acting injectable)

25. Medically Assisted Treatment • Best treatment of addiction is medication + therapy • Better outcomes, fewer deaths • MAT is not “trading one addiction for another” • Many types of counseling can be effective • Several options for medications

26. Chronic Pain Management Vitaly Gordin, M.D.

27. Chronic Pain Management • Medical management • Interventional pain management procedures • Cognitive-behavioral therapy • Self directed home exercise program • Complimentary medicine • Acupuncture • Nutritional consult • Life style changes

28. Chronic Pain Management: Medical Management • Nonopioid analgesics • Acetaminophen • NSAIDs • Adjuvant medications • Antidepressants, such as TCAs, SNRIs • Anticonvulsants, such as gabapentin, pregabalin, topiramate, carbamazepine, etc.

29. Chronic Pain Management: Medical Management • Topical agents • Local anesthetics • Capsaicin • TCAs, NSAIDs, gabapentinoids • IV anesthetics: ketamine

30. Chronic Pain Management: Medical Management • Opioid analgesics • CDC declared opioid induced deaths as a national epidemic • Doctors wrote 72.4 opioid prescriptions per 100 persons in 2006 • Decreased 4.9% annually from 2012 through 2016 • Reaching a rate of 66.5 per 100 persons in 2016. • A record number of drug overdose deaths occurred in 2015 • 52,404, prescription or illicit opioids were involved in 63.1% of these deaths

31. Chronic Pain Management: Medical Management • Properly selected patients with findings on physical examination might benefit from chronic opioid therapy • Use screening tools • Opioid agreements • UDS (urine drug screen) • Pill count • PDMP • Doses higher than 90 MME are not recommended, but there are exceptions

32. Chronic Pain Management: Interventional Pain Management Procedures Spinal injections • Epidural steroid injections • Facet joint injections • Sacro-iliac joint injections • Radiofrequency ablation • Neuromodulation • Spinal cord stimulation • Dorsal root ganglion stimulation • Intrathecal therapies

33. Mental Health/Co-occurring Daniel Hornyak, M.D.

34. Mental Health/Co-occurring • 45% of Americans seeking treatment have dual diagnosis • Substance Abuse Disorder • Mental Health Illness • Substance Abuse Disorder • Criteria defined in DSM 5

35. Mental Health/Co-occurring • Most Americans recognize mental health is a biological problem • Still don’t want someone with mental illness as a neighbor or friend • Many try to self medicate • “Honey, just have a drink, it will calm your nerves” • Marijuana use • Self medication can lead to abuse

36. Mental Health/Co-occurring • Treated separate until 1990s • Sequential treatment was the norm • No longer a hard line between diagnoses or treatment • Integrated Approach now used • No single option for every combination • Must personalize

37. Mental Health/Co-occurring • Begin treatment mental health disorder at the same time as substance abuse • You don’t know which came first • Combination therapy • Medications • Behavior Modification • Coping Mechanisms • Modification of traditional techniques

38. Mental Health/Co-occurring • Early treatment is key • Integrated approach is necessary • Recovery occurs over months to years • Long term, community based approach is needed for success

39. Opioid ForumSeptember 15, 2017

40. Pregnancy & Newborns Susan Peck, D.O.

41. Pregnancy & Newborns • Opiate use in pregnancy increased 5 times in the last decade • Increase of NAS 5 times from 1.2 to 5.8 /1000 hospital births • Screening of pregnant women • Medically assisted treatment – methadone and buprenorphine • Medically assisted withdrawal during pregnancy

42. Pregnancy & Newborns • Prenatal care • Peripartum pain management • Postpartum care • Post operative pain management for discharge

43. Pregnancy & Newborns • NAS needs 3-5 days for evaluation - can be from MAT, narcotics or other psychoactive drugs • Screening needs to be universal • Keep mother and baby dyad together • Encourage breast feeding

44. Pregnancy & Newborns Future needs for opioid use in pregnancy: Obstetric research with optimal screening, treatment and care and postpartum care and medically supervised withdrawal in pregnancy Neonatal focus: • Better scoring system that helps determine pharmacologic management • Optimal nonpharm and pharm approaches to management • Information on long term effects of MAT • Understand genetics and train multidisciplinary providers

45. Emergency Medicine Greg S. Swartzentruber, M.D.

46. Emergency Medicine: Perspective

47. Emergency Medicine: The Problem • Many focus ED’s role as a pipeline for opioid prescriptions • EDs account for only 5% of opioids • ED physicians are low-risk providers • Contribute very little to opioids prescribed to patients with OUD

48. Emergency Medicine: The Opportunity

49. Emergency Medicine: The Warm Hand-Off • Evaluation by substance abuse specialist • Initiation of treatment • Direct referral to treatment

50. Emergency Medicine: The Solution The ED: The Solution? • Screening, brief intervention, referral to treatment (SBIRT) • Screening, treatment initiation, and referral (STIR)