Download Central City Concern`s

Opiate Use and Misuse in Oregon –
Efforts from a Healthcare for the
Homeless Clinic
Rachel Solotaroff, MD, MCR
Medical Director, Central City Concern
May 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
Drug poisoning mortality: rate and frequency by year and
select drug type, Oregon, 1999-2008
Oregon Public Health Division- Injury Prevention Program
450
12.0
11.0
400
Number of heroin deaths
350
Number of prescription opioid deaths
10.0
9.0
Rate of drug poisoning
300
8.0
7.0
250
6.0
200
5.0
150
4.0
3.0
100
2.0
50
Crude mortality rate per 100,000
Number of drug-related poisonings
Number of cocaine deaths
1.0
0
0.0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
*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
Unintentional poisoning hospitalization- rate and
frequency by drug category and year, Oregon 1997-2007
Oregon Public Health Division- Injury Prevention Program
Other drugs (44 categories combined)
35
Opioid analgesics (+ methadone)
1200
Rate of unintentional poisoning
30
1000
25
800
20
600
15
400
10
200
5
0
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Data source: Oregon Hospital Discharge Index
Oregon Health Authority, Office of Disease Prevention and Epidemiology
Crude hospitalization rate per 100,000
Number of drug-related poisonings
1400
Who’s At Risk?
Age distribution of prescription opioid
deaths, Oregon, 1999-2009
Oregon Public Health Division- Injury Prevention Program
40
33.1
35
Percent
30
26.5
25
18.7
20
15
10.98
8.66
10
5
0.9
0
Oregon Health Authority, Office of Disease Prevention and Epidemiology
1.46
0.51
The Role of Methadone
Drug poisoning mortality: the role of
methadone, Oregon, 1999-2008
500
450
400
350
Oregon Injury Prevention Program
Public Health Division
Supportive
Housing
Count
300
250
200
150
100
50
0
1999
2000
2001
2002
2008 data are preliminary. Categories are not
mutually exclusive- many deaths
sumultaneously involve several types of drugs.
Includes only deaths with an X40-X44 & Y10Y14 ICD-10 code for underlying cause of death
(unintentional and undetermined intent).
2003
2004
2005
2006
2007
2008
All drug and medication-related
deaths combined
All prescription opioid-related
deaths combined
Methadone-related deaths
Methadone: Grams Sold and Death Rate.
Grams methadone sold per 100,000 persons
6000
4.5
4
Grams sold/100,000 population
5000
3.5
Methadone death rate
4000
3
2.5
3000
2
2000
1.5
1
1000
0.5
Oregon Public Health Division- Injury Prevention Program
0
0
1999
2000
2001
2002
2003
2004
2005
2006
Rate of methadone-associated poisoning deaths per
100,000 persons
Retail distribution of methadone in Oregon and poisoning mortality rate
asociated with methadone in Oregon, 1999-2006
Note: grams sold on left axis, death rate on right axis
Sources: US Dept. of Justice, Drug Enf orcement Administration, Of f ice of Diversion Control, Automation of Reports and
Consolidated Orders System (ARCOS); Oregon Center f or Health Statistics mortality data f iles. Includes unintetnional and
undetermined intent deaths.
Factors Among Methadone Decedents
 41% prescribed methadone; 30% no Rx
 Prescriptions: 43% pain; 26% methadone
maintenance
 In 77%, abuse contributed to death
 75% history of substance abuse
 21% history of substance abuse treatment
 52% history of mental illness
Sample N=56
Oregon Health Authority, Office of Disease Prevention and Epidemiology
Pain Medication Misuse
2008: Oregon is 5th highest state for nonmedical use of
prescription painkillers*
6.6% of persons >12 years
8.2% of persons 12-17 years
17.9% of persons 18-25 years – highest in any US
state
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
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
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
 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
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
Chronic Pain Recovery Pyramid
Strengthening Our Systems and Supports
High addiction risk:
•
•
•
Brief relapse
Early Recovery
Minimal support
Level Three
Hot Sauce
Weekly
Graduation Criteria:
-- Level 3: completion of Hot Sauce
-- Level 2:
Progress toward goals
Engaged in Behavioral health (if nec)
Reduction in opiate dosage
Acupuncture
Low addiction risk BUT:
•
•
•
Low self-management
Low social supports
Low function/activity
Level Two
RENEW
Monthly Group Visits with OT/PCP
Behavioral Health Assessment or Impact
Monthly “Activity Groups”
Low addiction risk:
•
•
•
Good self-management
Good support
Good function/activity
Level One
Primary Care Only
q 2-3 mo visits
Risk Management
-- UDS – q 3 months
-- pill count – q 6 months
-- ADR’s – q 3 months
-- PDMP: annually
Chronic Pain Recovery Program Road Map
4 weeks
Income
& Employment
CP Identified at
Volunteering,
Intake:
Training, Jobs
-- ROI’s
-- CP
acknowledgemt
PCP
Appt #1
H&P, Record Review, UDS, OPDMP query
PCP
Appt #2
OT
Assess
-- BH Screen:
CSRC Reviews Data and recommends:
• ORT
-- No Controlled Substances + Care Plan
Recs -- OR --
• PHQ
• GAD-7
If + BH
Screen
• PTSD Screen
-- Controlled Substances + Level of Care +
Care Plan Recs:
• Hot Sauce (Level 3)
Behavioral
Health
• RENEW Provider Groups (Level 2)
• Primary Care Only (Level 1)
• Other recs such as BH, medication
regiment, monitoring guidelines, etc.
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!