State Responses toRx Drug and Heroin Abuse

Presenters:• Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy• Ralph Orr, Director, Virginia Prescription Monitoring Program, Virginia

Department of Health Professions• Michael Landen, MD, MPH, State Epidemiologist, New Mexico

Department of Health• Maggie Hart Stebbins, County Commissioner, Bernalillo (NM) Board of

Commissioners

Advocacy Track

Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare

Disclosures

Maggie Hart Stebbins; Michael Landen, MD, MPH; Ralph Orr; Dean Wright, RPh, PMP; and Mark D. Birdwhistell, MPA, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Outline how Virginia’s new Health and Criminal Justice Data Committee is designed to respond to concerns before they become crises.

2. Explain Arizona’s state-wide prescriber report cards.

3. Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths.

4. Provide accurate and appropriate counsel as part of the treatment team.

Advocacy Track:State Responses to Rx Drug and Heroin

Abuse

Dean Wright, RPhDirector of Arizona’s Controlled Substances

Prescription Monitoring Program

Disclosure statement:Dean Wright, RPh, has disclosed no

relevant, real or apparent personal or professional financial relationships

with proprietary entities that produce health care goods and services.

Learning Objective:Explain Arizona’s state-wide

prescriber report cards.

The Strategies1. Reduce Illicit Acquisition and Diversion of Rx Drugs

2. Educate Prescribers and Pharmacists about “Rx Drug Best Practices” and emphasize responsible prescribing

3. Enhance Rx Drug Practice and Policies in Law Enforcement

4. Increase Public Awareness about the Risks of Rx Drug Misuse

5. Build Resilience in Children and Adults

Strategy #1: Reduce Acquisition

• Proper Disposal• Permanent drop boxes• Take-back events• Community education and awareness

• Proper Storage• Community education and awareness

• Increase the use of the PDMP• More law enforcement, prescribers and dispensers signed up and using the

PDMP• A data feedback system for prescribers to self-monitor prescribing practices

Specialty CountOfSpecialtyPathology 21Hospice 24Addiction Medicine 33Preventive Medicine 56Physical Medicine & Rehab 104Optometry 125Podiatry-Surgical 130Podiatry-General 141Dentists-Orthodontics 145Otolaryngology 148Dentists-Surgical 155Pain Medicine 164Urology 167Oncology 202Radiology 285Anesthesiology 305Neurology 362Naturopath 375OBGYN 847Psychiatry 1193Pediatrics 1204Other PA-APN 1426Surgery 1519Emergency Medicine 1543Dentists-General 2709Internal Medicine 4674Family Medicine 5483

23552

Arizona State Board of Pharmacy Controlled Substances Prescription Monitoring Program 1616 W. Adams, Suite 120 Phoenix, AZ 85007

February 18, 2016 «Prescriber_Name» «Degree» «Address» «City», «State» «Zip» Dear «Prescriber_Name» «Degree»: The Arizona State Board of Pharmacy, in collaboration with the Arizona Substance Abuse Partnership, is participating in an initiative to address the growing concern over prescription drug misuse and abuse in Arizona. The Rx Initiative involves stakeholders from the Arizona Department of Health Services, the Arizona Criminal Justice Commission, the Governor’s Office of Youth, Faith and Family, and local substance abuse prevention coalitions. A major focus of the Rx Initiative involves promoting responsible prescribing and dispensing practices among medical professionals in Arizona. In an effort to help you monitor your own prescribing habits, please find an attached report card that details your prescribing patterns related to the types of prescription medications of interest to the Initiative. These medications were chosen based on data that identified them as the most commonly prescribed and the most commonly misused by youth and adults. Additionally, these drugs account for the majority of drug-related Emergency Department visits and poisoning deaths in Arizona. The data provided by the report card is for your information only. Please take a moment to review the report card to compare your prescribing practices to those of your colleagues, and help us promote responsible prescribing in Arizona. If you are an outlier (i.e., prescribing at least 1 Standard Deviation above the mean compared to your colleagues), we encourage you to consider if your prescribing practices follow best practice guidelines for your medical specialty. You can find the Arizona Opioid Prescibing Guidelines on the Arizona Department of Health Services website at http://azdhs.gov/audiences/clinicians/index.php#guidelines-recommendations-rx-guidelines. We also encourage you to educate your patients about the risks of Rx drug misuse and proper storage and disposal methods. Locations of permanent drop boxes can be found at www.dumpthedrugsaz.org . If you have not yet done so, please go to the website below to sign up for access to the Prescription Drug Monitoring Program (PDMP) database: https://pharmacypmp.az.gov/. The PDMP is an essential tool for checking your patient’s medication history, for monitoring their drug therapy, and for minimizing misuse. If you have any questions, please do not hesitate to call the Arizona State Board of Pharmacy at 602.771.2748 or 602.771.2732. ______________________________ ______________________________ Debbie Moak John A Blackburn Jr Arizona Substance Abuse Partnership Executive Director, The Governor’s Office of Youth, Faith and Family Arizona Criminal Justice Commission ______________________________ ______________________________ Cara M. Christ, MD Dean Wright Director, Monitoring Program Director, Arizona Department of Health Services Arizona State Board of Pharmacy

CSPMP Report Cards

Report cards for the 3rd Quarter of 2015 1543 mailed on 12/28/15

8429 emailed on 1/4/16 to 1/5/16

So far:66 returned envelopes

935 bounced emails

CSPMP Report Cards

Next set of report cards for the 4th Quarter 2015 will go out the 1st week

of March 2016.

QUESTIONS?Arizona State Board of Pharmacy

Web page: https://pharmacypmp.az.gov

Dean Wright, CSPMP DirectorArizona State Board of Pharmacy

1616 W. Adams, Suite 120P.O. Box 18520

Phoenix, AZ 85005602-771-2744

Fax: 602-771-2748dwright@azpharmacy.gov

Advocacy Track: State Responses to Rx Drug and Heroin Abuse

Ralph OrrDirector, Virginia’s Prescription

Monitoring Program

Disclosure Statement

• Ralph Orr has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.”

Objectives

• Discuss recommendations of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse

• Outline how Virginia’s new Health and Criminal Justice Data Committee is designed to respond to concerns before they become crises.

Task Force Establishment & Structure

19

• Healthy VA Plan: Executive Order 29

• Co-chaired by Secretary Hazel & Secretary Moran

• Five meetings between November 2014 and September 2015, resulting in 51 recommendations

• 32 members, 5 workgroups

Education Treatment Storage & Disposal Data & Monitoring Law Enforcement

2 Co- chairs

32 multi-disciplinary, bipartisan members

5 workgroups

Recommendations: Major Themes

20

Access to Naloxone

Maximization of Prescription

Monitoring Program

Provider education and proper

prescribing/dispensing

Access to and availability of

treatment

Drug courts and incarceration-based

programs; further support for law enforcement

Information and Data

Maximizing the PMPUsing the Prescription Monitoring Program to its maximum benefit to decrease overdose and promote legitimate use of controlled substances.

21

Access to and Availability of TreatmentTreating opioid and heroin addiction requires a complex and individualized set of services, including Medically Assisted Treatment, group and individual counseling, and peer supports.

Drug Courts & Law Enforcement Support

“We cannot arrest our way out of this problem.”

22

Provider education and proper prescribing/dispensing

• Students: – Medical School curricula– Social Work curricula

• Medical residents:– Loan forgiveness for Addiction

Medicine residency program– Grand Rounds inclusion

• Practicing Providers:– Mandate and/or incentivize

Continuing Medical Education (CME) for current providers

Continuing Action

23

Leadership on

cross-secretariat coordination efforts

Engagement from

agencies (VDH,

DBHDS, DHP, DCJS)

and legislature

Health and Criminal Justice

Data Committee

Development of Website

PMPMed Examiner

EDData

State Police

ForensicsCorrectionsJuvenile Justice

Workforce data

PROBLEM: LACK OF COORDINATED ANALYSIS OF DATA

HEALTH AND CRIMINAL JUSTICE DATA COMMITTEE: PROVIDES MECHANISM

FOR COORDINATED ANALYSIS

Virginia Prescription Opioid DataComparing Hospitalizations to Fatal Overdoses

FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY20150

100

200

300

400

500

600

700

800

900

1000

Hospitalizations Fatal OD

Coun

t of H

ospi

taliz

ation

s and

Fat

al O

D

Data Sources: OCME Fata Drug Overdose Quarterly Report (2015 data are projected, preliminary figures); OFHS response to data request 12/30/2015.

Virginia Heroin DataComparing Hospitalizations to Fatal Overdoses

FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY20150

50

100

150

200

250

300

350

Hospitalizations Fatal OD

Coun

t of H

ospi

taliz

ation

s and

Fat

al O

D

Data Sources: OCME Fatal Drug Overdose Quarterly Report (2015 data are projected, preliminary figures); OFHS response to data request 12/30/2015

Submissions to Virginia Department of Forensic Science: Prescription Opioids and Heroin

CY20

02

CY20

03

CY20

04

CY20

05

CY20

06

CY20

07

CY20

08

CY20

09

CY20

10

CY20

11

CY20

12

CY20

13

CY20

14

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

RxOpioids Heroin

Case

s Sub

mitt

ed

Data Source: DFS monthly submission to the National Forensic Laboratory Information System (NFLIS), shared with DCJS

Opioids Prescribed in VirginiaSix Drugs Represent 90% of Opioid Prescriptions in First

Half of 2015

Hydrocone SA Oxycodone SA Tramadol SA Buprenorphine Codeine Hydromorphone0%

10%

20%

30%

40%

50%

60%

2010JanJunPct 2011JanJunPct 2012JanJunPct 2013JanJunPct 2014JanJunPct 2015JanJunPct

Data Sources: Brandeis University report, 11/23/2015. That report used Virginia Prescription Monitoring Program database as its source.

TASK FORCE WEBPAGE:Virginia Governor's Task Force on Prescription Drug and Heroin Abuse

• CONTACT INFORMATION– Phone #: 804-367-4566– Fax 804-527-4470– Email- ralph.orr@dhp.virginia.gov– Virginia's Prescription Monitoring Program

Advocacy Track: State Response to Rx Drug and Heroin Abuse

Michael LandenState Epidemiologist

New Mexico Department of Health

Disclosure

Michael Landen, MD, MPH, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Approved Learning Objectives

Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths.

19901992

19941996

19982000

20022004

20062008

20102012

201405

1015202530

Drug Overdose Death RatesNew Mexico and United States,

1990-2014New MexicoUnited States

Year

Deat

hs p

er 1

00,0

00 p

erso

ns

Rates are age adjusted to the US 2000 standard populationSource: United States (CDC Wonder); New Mexico (NMDOH BVRHS/SAES, 1990-1998,2014 ; NM-IBIS, 1999-2013)

Drug Overdose Death Rates Leading States, U.S., 2014

Rank StateDeaths per 100,000

1 West Virginia35.5

2 New Mexico27.3

3 New Hampshire26.2

4 Kentucky24.7

5 Ohio 24.6

U.S.14.7

Sources: CDC Wonder Rates are age-adjusted to the 2000 US Standard Population.

Drug Overdose Death Rates for Selected Drugs, NM, 1990-2014

19901992

19941996

19982000

20022004

20062008

20102012

20140

2

4

6

8

10

12

14

Heroin Prescription Opioids MethamphetamineCocaine Sedative-hypnotics

Deat

hs p

er 1

00,0

00 p

opul

ation

Drug categories are not mutually exclusive. Source: Office of the Medical Investigator; UNM/GPS population

Drug Overdose Death Rates by Census Tract Poverty Level*

New Mexico, 2009-2013

Less than 5% 5 - 9.9% 10 - 19.9% 20 - 29.9% 30% - 39.9% 40% or more0

5

10

15

20

25

30

35

15.6 16.8

23.0

27.129.9

23.8

Deat

hs p

er 1

00,0

00 P

opul

ation

*Poverty level is the percentage of persons of all ages in the decedent’s census tract living at or below 100% of Poverty. Drug Overdose deaths are defined by ICD 10: X40-X44, X60-X64, X85, Y10-Y14.Rates have been age-adjusted to the standard U.S. 2000 population. Source: NM Vital Records and Health Statistics, U.S. Bureau of the Census, American Community Survey

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

0.0

5.0

10.0

15.0

20.0

25.0

30.0

MME of Opioids Sold and Overdose Death Rates

NM, 2001-2014

Morphine equivalents soldDrug OD Death Rate

Mor

phin

e E

quiv

alen

ts (k

g) p

er 1

0,00

0 po

p

Ove

rdos

e de

aths

per

100

,000

pop

Buprenorphine and Methadone excluded from total morphine equivalents; Source: DEA AR-COS sales data; NMDOH BVRHS

New Mexico Mechanisms - 2011

• 7 licensing boards for each controlled substance prescribers profession

• PMP in Board of Pharmacy with shared access for Department of Health via regulation

• Naloxone widely distributed alongside syringe exchange

2012 Legislative Session

• 3 bills introduced– Opioid Prescribing Limits and PMP bills failed

• Pain Relief Act revised– Mandatory continuing education for prescribers– Required licensing boards to have chronic pain

management rules– Established Governor’s Council on overdose

prevention and pain management

Council

• Meets every 1- 2 months• Annual recommendations to Governor• Voting members include Department of

Health, licensing boards, professional associations, consumers, chronic pain patients, pain management specialists– Some licensing boards not voting members– Many others attend and participate

Improving Prescribing

• Council recommended PMP move from data within 7 days to within one day - implemented

• Reviewed licensing board chronic pain management rules

• Reviewed overdose death – PMP linked data• Reviewed prescriber report cards• Reviewed quarterly prescribing measures• Recommended PMP check with each opioid Rx

Percent of Patients with No PMP Review by Opioid Use Category, NM, 2014

1 prescription < 90 days 90-180 days 180-330 days Full Time0

20

40

60

80

100 9381

5642

31

1 year Opioid Use Category

Perc

ent o

f pati

ents

Source: NM Prescription Monitor-ing Program

Naloxone Access

• Council recommended Naloxone for Medicaid formulary

• Brought Medicaid managed care organizations together to work on reimbursement

• Regular updates on naloxone availability including availability by community/overdose death rates

• Recommended standing order and statute

Naloxone Distribution and Reported Reversals, NMDOH Programs, NM, 2010-2014

Source: NM DOH Harm Reduction Program and Co-Prescription Pilot Program

2011 2012 2013 20140

1000200030004000500060007000

Doses dispensed

Num

ber

2011 2012 2013 20140

100200300400500600700800900

1000

Reported Reversals

Pharmacist Prescriptive Authority• Based on 2002 law which provided pharmacists prescriptive

authority– The Board of Pharmacy adopts regulations and protocols governing

certification for specified “dangerous drug therapies”• Vaccinations, emergency contraception, tobacco cessation

drugs, and tuberculosis testing are allowed by certification• Naloxone certification was established by regulation in 2014

– Training is provided by the NM Pharmacist’s Association and certification is maintained by completing 2 hours of CE every 2 years

– About 180 pharmacists have been certified to date• Reporting system in place

– About 200 reports of persons prescribed naloxone by pharmacists

Medicaid Claims for Naloxone from Outpatient Pharmacies, NM January 2013- June 2015

Source: NM HSD Medicaid Claims; NM PMP

Jan-Jun 2013 Jul-Dec 2013 Jan-Jun 2014 Jul-Dec 2014 Jan-Jun 20150

20

40

60

80

100

120

0 1

17

66

100

Six month time period

Num

ber o

f cla

ims

Treatment Availability

• Chronic pain patient presentations– Chronic pain survey process developing

• Buprenorphine barriers and access reviewed• Recommended end to Medicaid pre-

authorization• Tracked opioid treatment need and actual use

disparity

Methadone

Buprenorphine/Naloxone

Heroin

Prescription Pain Relievers

Abus

e or

Dep

ende

nce

0 2000 4000 6000 8000 10000 12000

Estimated Number of People with Abuse/De-pendence on Opioids and Numbers of People in

Treatment, NM, 2014

Number of PeopleSource: NM Treatment Need Estimates, NMDOH; NM Prescription Monitoring Program; NM Behavioral Health Services Division

2016 Legislative Session

• Naloxone– Standing order and storage bills passed– Special meeting of council to implement standing order

process• Prescription Monitoring Program

– Floated every check for every opioid Rx, – initial bill had check for initial and q 3 month– ended up with 4 day short prescription exception– Council will lead joint process to revise 7 licensing board

chronic pain management rules

Recommendations

• Develop and maintain a state-level overdose prevention policy group– Transparency particularly around legislation– Hope to add a smaller, parallel state agency group

• Develop indicators for the group with regular data updates

• Establish a regular cycle for developing recommendations

• Don’t get complacent – the overdose epidemic and interventions constantly change

Advocacy Track: State Response to Rx Drug and Heroin Abuse

Disclosure

Maggie Hart Stebbins, Bernalillo County Commissioner, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Approved Learning Objectives

Describe New Mexico’s model for stakeholder collaboration to reduce opioid overdose deaths.

Maggie Hart Stebbins, Bernalillo County Commissioner

• Joined the Bernalillo County Commission in 2009.

• Actively engaged in efforts related to behavioral health, including: – Bernalillo County Opioid Accountability Initiative.– Bernalillo County Criminal Justice Review

Commission– Bernalillo County Behavioral Health Initiative

Bernalillo County

• Located along the middle Rio Grande of New Mexico

• Largest population in the State of New Mexico, with more than 675,000 residents

• Includes the City of Albuquerque

Images courtesy of marblestreetstudio.com

19901991

19921993

19941995

19961997

19981999

20002001

20022003

20042005

20062007

20082009

20102011

20122013

20140

5

10

15

20

25

30

35

40

Total Overdose Death Rate, Bernalillo County and New Mexico, 1990-2014

Bernalillo Co.

New MexicoDea

ths p

er 1

00,0

00 p

op

Rates age adjusted to the US 2000 standard populationSource: Bureau of Vital Records and Health Statistics, UNM/GPS population est.

Source: New York Times: How the Epidemic of Drug Overdose Deaths Ripples Across America. January 19, 2016

New Mexico Overdose Deaths, 2003-2014

Bernalillo County Metropolitan Detention Center (MDC)

• Bernalillo County is responsible for the operations and maintenance of the MDC, which comes at a cost of $84M for fiscal year 2016 and represents 30% of the County’s General Fund budget of $281M.

• Under court order to reduce jail population, which in 2012 was at 2800, and today is at approximately 1400, a 50% reduction.

• Accomplished as result of Bernalillo County Criminal Justice Review Commission, and Bernalillo County Adult Detention Reform team.

• Their efforts have highlighted the need for increased and better coordinated behavioral health services in our community, along with judicial reforms to make the system more efficient.

• 60% of MDC inmates with mental health, substance use or co-occurring • disorders• MDC is the largest behavioral health care provider in NM.

Healing Addiction in Our Community (HAC)

• Formed in April 2010• To educate, advocate,

raise awareness• 2014 opened Serenity

Mesa Youth Recovery Center, providing residential rehabilitation services to youth ages 14-21.

• Made up of community members, health and social service providers, educators, and other private and public employees that serve County residents

• History of bringing people together to explore public health concerns• Until last year was an official part of BernCo Government, today is it’s

own non-profit. • Experienced and highly skilled facilitator, Marsha McMurry Avila,

serves as the Executive Director.

bchealthcouncil.orgCollective Impact Initiatives

BERNALILLO COUNTYOPIOID ACCOUNTABILITY INITIATIVE

“Turning the Curve on Opioid Abuse in Bernalillo County”

SUMMIT PLANNING COMMITTEEFocused on identifying recommendations, indicators,

panelists and format for first Summit , 20 multi-sectoral members representing:

• Advocates, community activists, drug policy analysts, data analysts• Albuquerque Health Care for the Homeless• Bernalillo County Community Health Council• Bernalillo County Department of Substance Abuse Programs/MATS• Bernalillo County Urban Health Extension• City of Albuquerque Division of Health & Human Services• Heroin Awareness Committee (Healing Addiction in Our Community)• Molina Healthcare• New Mexico Department of Health – Health Promotion• New Mexico Department of Health – Office of Injury Prevention• New Mexico Department of Health – Turquoise Lodge• Presbyterian Healthcare Services• UNM Prevention Research Center for Education Policy Research• UNM Preventive Medicine• UNM Urban Health Partners – Pathways to a Health Bernalillo County• UNM Center for Alcoholism, Substance Abuse & Addictions (CASAA)• UNM RWJF Health Policy Center

SUMMIT PLANNING

COMMITTEE

SUMMIT #1 September

19, 2013

IMPLEMENTATION TEAMS

PRIMARY PREVENTION

NARCAN

TREATMENT

LAW ENFORCEMENT/

CRIMINAL JUSTICE

COORDINATING COMMITTEE

INTERIM UPDATE

MEETING June 2014

SUMMIT #2January 2015

BERNALILLO COUNTY OPIOID ACCOUNTABILITY INITIATIVE TIMELINE (Fall 2012 – Winter 2015)

August 2012 -------------September 2013 ------------------>December 2013 ---------------------------->June 2014-->Fall 2014

Four Implementation Teams with volunteers from Summit - plus others – have met monthly to:

· strategize about recommendations for their specific area, including identifying decision-makers who are key players to bring to the table

· select indicator(s) as target to measure progress toward desired outcome(s)

· inventory available services/gaps in their area, identifying need for additional resources

· provide ideas for next Summit

PRIMARY PREVENTION IMPLEMENTATION TEAM

What works or would work to "turn the curve" on this problem?RECOMMENDATIONS FOR ACTION

• Expand access to drug counseling and prevention services for high school and middle school students including appropriate referrals, working to gain reimbursement coverage from Medicaid

• Support policies to expand evidence-based early childhood support programs, including home visiting focusing first on low-income families

• For pain control, promote evidence-based alternatives for Rx opioids, such as chiropractic or other physical medicine

• Reduce supply of Rx opioid pain medication by increasing access to and usage of Prescription Monitoring Program database AND promoting prescribing guidelines to limit over-prescription of opioids

What would work to "turn the curve" on this problem?

RECOMMENDATIONS FOR ACTION

• Distribute naloxone to persons being released from MDC and their families• Restructure P&P policies to allow for parolees to have naloxone rescue kits while on parole• Assure all police officers are carrying naloxone and trained in its use• Support implementation of authorization allowing pharmacists to prescribe naloxoneo Support development of MCO reimbursement mechanisms for kits and

education/consultationo Assure naloxone rescue kits are stocked at all pharmacies

• Advocate for all providers to co-prescribe naloxone with opioid pain meds for chronic pain management

• Make naloxone and training available to agencies with outreach programs for injection drug users, treatment centers and methadone clinics

• Make naloxone available at all public health offices as walk-in sites

NARCAN IMPLEMENTATION TEAM

Make availability of naloxone normal and universal

TREATMENTIMPLEMENTATION TEAM

What works or would work to "turn the curve" on this problem?

RECOMMENDATIONS FOR ACTION

• Increase MD participation in prescribing• Continue MAT for MDC inmates already in treatment when incarcerated• Offer pre-release MAT to MDC inmates not yet in treatment • Assure access for uninsured populations, including those not eligible for coverage• Expand buprenorphine beyond detox to ongoing maintenance treatment when appropriate (Turquoise

Lodge and MATS)• Address issue of drug courts excluding people on MAT• Address BHSD guidelines allowing only psychiatrists to prescribe buprenorphine and no payment for

methadone• Address private insurance payment for methadone• Address VA lack of provision and payment for methadone• License mid-level practitioners to prescribe buprenorphine • (issue of federal regulations)

1. Expand access to medication-assisted treatment (MAT)

TREATMENT continued

RECOMMENDATIONS FOR ACTION

• Expand number and capacity of residential and inpatient programso Work with Medicaid, Centennial Care MCOs and private insurance to provide coverage/

reimbursement o Assure access for uninsured populations, including those not eligible for coverage

• Duration of coverage for specific levels of intervention should be flexible and tailored to patient needs

• Assure identification and treatment of co-occurring disorders• Eliminate need for diagnosed co-occurring condition as a requirement for Medicaid funding of

treatment of alcohol/drug dependency• Include wrap-around support services as integral part of funding for treatment services, including

assistance finding housing/jobs• Identify and offer enrollment to all persons who are drug users or at risk for opioid use and are

eligible for Medicaid, especially persons being released from incarceration

2. Expand full array of treatment services aligned with ASAM guidelines

TREATMENTcontinued

TREATMENT continued

RECOMMENDATIONS FOR ACTION

• Develop a comprehensive inventory/mapping of current treatment services to determine gaps in capacity and levels of care as basis for an effective, coordinated system

• Develop current, consistently updated database of services accessible to providers and community (including eligibility criteria and program capacity)

• Identify opportunities for enhanced linkages among different components of the system• Develop shared measurement criteria to allow for evaluation of system linkages and

accurate cost reports• Propose realignment of resources to support prioritized services in alignment with agreed-

upon principles • Explore feasibility and appropriately plan for expansion of County DSAP as nucleus of a

much-expanded integrated treatment system• Assure integration of MDC into treatment system linked to community providers/resources

3. Develop comprehensive and coordinated treatment system in Bernalillo County

TREATMENTcontinued

LAW ENFORCEMENT/CRIMINAL JUSTICEIMPLEMENTATION TEAM

What works or would work to "turn the curve" on this problem?RECOMMENDATIONS FOR ACTION

• Increase programs offering alternatives to incarceration • Increase capacity of court system to expedite proceedings and reduce time waiting for

verdicts and sentencing • Assemble stakeholders to assess feasibility of LEAD pilot by either APD or County

Sheriff’s Department

1. Reduce the number of people with substance use disorders who are incarcerated

LAW ENFORCEMENT/CRIMINAL JUSTICEcontinued

RECOMMENDATIONS FOR ACTION

• For persons already under medication-assisted treatment (MAT) at the time of incarceration, continue methadone and Suboxone during incarceration

• Conduct a pilot for pre-release induction of Suboxone and treatment with Vivitrol

• Prior to or upon release, arrange for Medicaid enrollment for those eligible• Set up linkages between treatment providers and inmates• Arrange for post-release social services and medical follow-up including MAT,

and distribute Narcan• Make indicated prevention programs available for incarcerated individuals

with low-level substance abuse • Increase amount of discharge prescriptions from 3 days to 30

2. Provide effective treatment services for those who are incarcerated and upon release

WHERE ARE WE NOW? • Continued rise is opioid deaths in NM and Bernalillo County• Numerous tragic encounters between law enforcement and people struggling with

substance use and mental health disorders that have heightened awareness of community service needs.

• City of Albuquerque, U.S. Dept. of Justice Settlement Agreement includes several provisions that will require an investment by the City into behavioral health community resources, education and training for officers

• Bernalillo County 1/8 cent GRT for Behavioral Health & BC Behavioral Health Initiative:

Connect the Dots Fill the Gaps Leverage Resources to Maximize Impact

WHERE ARE WE NOW?Cont’d

Treatment -- Managing prescription opioids:

Medicaid expansion has started targeting enrollment for persons at risk of addiction: example incarcerated persons.

MDC has turned around in terms of interest in helping with addiction, including maintaining MAT for persons who are on methadone at time of incarceration and active planning for drug treatment for persons being released from incarceration.

Medicaid has begun covering buprenorphine and clinician visits for medication-assisted Treatment (MAT).

WHERE ARE WE NOW?Cont’d

Naloxone:

NM pharmacists can have prescription authority for naloxone.

2016 Legislative Session, HB 277, passed and is waiting for the Governors signature. If signed, it will allow licensed prescribers new authority to provide standing orders for unnamed persons to obtain naloxone. This will approximate OTC status naloxone without losing third party coverage for it still being a prescription drug.

WHERE ARE WE NOW?Cont’d

Prevention:• Focus on reducing supply of prescription opioids through take-backs, and control of

excess prescribing.

• NM was early in establishing its PMP; now fully running with required registration. • Plans are underway to have face-to-face education encounters with prescribers who

are outliers at the high end of opioid volumes.

• Licensing boards requiring all prescribers to have pain management education and to participate in the PMP.

• Focus on schools for education and early intervention.

• Focus on early childhood intervention (Nurse Family Partnership) targeting high-risk families.

IMPLEMENTATION TEAMS

PRIMARY PREVENTION

NARCAN

TREATMENT

LAW ENFORCEMENT/

CRIMINAL JUSTICE

ACTION TEAM

COORDINATING

COMM

ALIGNED ACTION

SUMMIT

#2

Jan

2015

BERNALILLO COUNTY OPIOID ACCOUNTABILITY INITIATIVE TIMELINE (as of Spring 2016)

PRIMARY PREVENTION

NARCAN

TREATMENT

LAW ENFORCEMENT/

CRIMINAL JUSTICE

STRATEGY GROUPS

ACTION TEAM

ACTION TEAM

ACTION TEAM

ACTION TEAM

ACTION TEAM

ACTION TEAM

ACTION TEAM

Jan 2015 (Jan 2015 to Jan 2013)

Jan 2016 Feb 2016

New Mexico Heroin and Opioid Prevention and Education (HOPE) Initiative

• Launched January 2015• Collaboration between New Mexico Office of U.S. Attorney’s Office, and• University of New Mexico Health Science Center, in partnership with the• Bernalillo County Opioid Accountability Initiative • Five Components:

– Prevention & Education– Treatment– Law Enforcement– ReEntry– Strategic Planning

Challenges Ahead

• Educating elected officials and government bureaucracies• Poor drug treatment infrastructure, personnel, and insurance coverage• Major issues with parity enforcement – Medicaid a particular concern• Stigma of addiction• Need to treat addiction as a chronic disease to shift from blame and punishment • The need to scale up. We have made progress in communication across

stakeholders, but the requirements for scaling up to impact the indicators will require new tools to build systems of planning and collaboration. Our agencies and bureaucracies are not prepared to accept a new set of priorities that will compete for budget and disruption familiar alignments. Ultimately it will depend on strong executive leadership.

• MAT-Induction at MATS & MDC?• Add Buprenephorine to MDC MAT options?

State Responses toRx Drug and Heroin Abuse

Presenters:• Dean Wright, RPh, PMP Director, Arizona State Board of Pharmacy• Ralph Orr, Director, Virginia Prescription Monitoring Program, Virginia

Department of Health Professions• Michael Landen, MD, MPH, State Epidemiologist, New Mexico

Department of Health• Maggie Hart Stebbins, County Commissioner, Bernalillo (NM) Board of

Commissioners

Advocacy Track

Moderator: Mark D. Birdwhistell, MPA, Vice President for Administration and External Affairs, University of Kentucky HealthCare