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11/1/2017
1
A Crisis
Identified: A
Public Health
Response to
Substance Use
Disorders
Amanda Tuura, RN, BSN
Gianna Ventura, RN, BSN
Disclosure
– Kenosha County Department of Human Services, Kenosha
County Detention Center, Department of Corrections and
Professional Services Group do not have any relevant
financial relationships with any commercial interests
Objectives
– Statistics: National, State, and Local Data
– Current Efforts in Kenosha County, WI
– History of CADTP
– Planning Process
– Referral Process
– Injection Appointment
– Program Data
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Statistics: Nationwide
– 2015: 52,404 lethal drug ODs
(the leading cause of accidental death in the US)
– 20,101 OD deaths related to prescription pain relievers
– 12,990 OD deaths related to heroin
– Each day, 91 Americans die everyday from an opiate overdose
– 46 die specifically from an overdose related to prescription pain medication
– Each day, more than 1,000 individuals seen in E.R. for misuse or abuse of
prescription opioids
– 4 in 5 new heroin users started out misusing prescription painkillers
Statistics: Nationwide
Among the more than 64,000 overdose deaths in 2016, 20,000 were related to fentanyl and fentanyl analogs
Statistics: Statewide (WI)
– Department of Health Services (DHS) report, “Select Opioid-Related Morbidity and Mortality Data for Wisconsin.”
– 2006-2015 - 880% increase in
overdose deaths involving heroin
– 2006—0.5/100,000
– 2015—4.9/100,000
– The rate of opioid OD deaths nearly doubled over the decade
– 2006—5.9/100,000
– 2015—10.7/100,000
– Heroin overdose occurred six
months, on average, after patients stopped utilizing prescription opioids
– WI drug OD > crashes, suicide, breast cancer, colon cancer, firearms, influenza or HIV
633
792 795
873
0
100
200
300
400
500
600
700
800
900
1000
2012 2013 2014 2015
WI DRUG RELATED DEATHS
WI Deaths
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Statistics: Local Data (Kenosha
County)
– OD deaths doubled in last 5 years
– 2015: 1,500 ER visits for issues involving OD
– 2017
– 36 confirmed toxicities
– 27 accidental
– 4 undetermined
– 4 suicides
– 1 pending manner of death
– 13 r/t fentanyl or fentanyl analog
– 6 in 2016
– 14 pending toxicology
Toxicities: Include accidental, suicide,
and undetermined
28
48 4750
44
54
0
10
20
30
40
50
60
2011 2012 2013 2014 2015 2016
MEDICAL EXAMINER DATA
Toxicities
Current Efforts
– Medication Lockboxes and Drop
Boxes
– Behavioral Drug Court
– Kenosha County Substance Abuse
Coalition
– Kenosha County Opioid Task Force
– Adult Death Review (SDART) Team
– Naloxone (Narcan®) Dissemination
– Comprehensive Alcohol and Drug
Treatment Program (CADTP)
History of CADTP
– Kenosha County Executive
– Cost Analysis—toxicity deaths, incarceration & frequent hospitalizations compared to cost of treatment program
– Toxicity Overdose Death—approximately $30,000
– Incarceration—Department of Corrections—$30,000/year
– Residential Treatment—$6,000-$12,000/month
– Within 1 week of release—60% relapse rate
– Cost of County Treatment Program— $7,400-$16,600/year
– Board Meeting
– 2016 Pilot Program: 6 months (initial)
– Secure Funding: $325,000
– Provide services to approximately 40-50 Kenosha County residents
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Initial Planning Process
– Establish Partnerships and Workflow
– Kenosha County Detention Center; Department of Corrections; Kenosha Visiting
Nurse’s Association; Kenosha County Department of Human Services; Professional
Services Group
– Identify Candidates for Program—Living Free
– Behavioral Health Assessment Completed
– Participation in Individual and Group Counseling Sessions
– Initial Health Assessment
– Transported from DOC to KCDOH for injection
What is Vivitrol?
– Injectable Naltrexone is a long acting injection,
administered once a month or every 28 days
– Injectable Naltrexone is NOT a standalone treatment method and should be combined with an alcohol or recovery treatment program
– Indications for injectable Naltrexone
– Treating alcohol dependence.
– Preventing relapse to opioid dependence AFTER opioid detox. Prior to receiving injection, client MUST BE opioid-free for a minimum of 7-10 days to avoid sudden withdrawal.
– Contraindications for injectable Naltrexone
– If still actively using or currently in withdrawal
– If pregnant or breastfeeding
– If allergic to Naltrexone
How Does Vivitrol Work?
– Vivitrol is an opioid blocker.
– Blocks the effects of opioids
in the brain’s reward system.
– Blocks those pleasurable or
euphoric feeling that can often
lead to addiction
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Referral Process
– Referrals received from Professional Services Group
– KCDC—Release date determined, client released from KCDC and presents
directly to clinic to receive first injection
– Community—Injection date determined with assistance of facilitator and
dependent on last reported date of usage
– District Attorney’s Office—Last date of usage determined, client released
from KARE center and presents directly to clinic to receive first injection
Assessment Process
– Multidimensional Assessment (MDA)
– Presenting Problem/Diagnosis -- Medical/Mental Health History
– Client Strengths -- Legal History
– Family History -- Treatment Goals
– Substance Use History
– Division of Health Assessment
– Include synopsis of program; gauge program participation
– Consents—KCDOH Authorization for Disclosure, Interagency Authorization for Disclosure, HIPPA, Medical procedure
– Health History Questionnaire—Discusses past/current history of substance use; Overdoses (Naloxone
utilized?); Social support ; Plan for treatment
– Initial lab work—CMP (LFT’s), CBC, HIV, Syphilis, Hepatitis B & C, CT/GC), urine drug screen; pregnancy test if female
– Review of MDA and Lab Results Completed by KCDOH Nurse Practitioner
Health History Questionnaire
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Injection Appointment
– Present to clinic at scheduled date and time
– Upon presentation, urine provided
– 12 panel and ETOH screen completed; If female, pregnancy test completed
– Naltrexone challenge initiated (25mg tablet)
– Health History Questionnaire completed
– MAT consent reviewed and signed by client
– 1st injection appointment—client receives Vivitrol® brochure, emergency pain management card, appointment card, bracelet, and dog tag
– Once naltrexone challenge determined to be negative, injection given
– Follow up appointment scheduled for lab work and/or next injection
– Lab work—completed 1, 3, 6, 9, and 12 months
– Injection scheduled every 28 days
Medication Assisted
Treatment Consent
Medication Assisted
Treatment Consent
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Emergency Pain
Management Supplies
Medication Assisted Treatment
Program Data
– Provided Services To: 141
– Current Enrollment in
Program: 44
– KCDC: 19
– Community: 13
– District Attorney: 12
– Successful Completion: 12
# OF INJECTIONS # OF CLIENTS
1 21
2 17
3 13
4 10
5 7
6 11
7 9
8 9
9 5
10 -
11 -
12 10
Medication Assisted Treatment
Program Data
– Male – 69% Female – 31%
– Average age – 38 years old
– Addiction History – 11 years of opiate use and 20 years of alcohol
use
– 75% of participants have a mental health history or diagnosis
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Medication Assisted Treatment
Program Outcomes
– 94% of participants report(ed) significant reductions in cravings (at
least 50%)
– 88% have or gained stable housing
– 82% are employed or were employed at discharge
– 93% have not recidivated
– Of the 274 drug screens performed by Health/PSG post initial
injection only 9 have been positive for opiates and 11 positive for
alcohol (less than 5%)
Future Projects
– Initiation of Suboxone Treatment
– Naloxone Kit at DOC Release
– EMS Treatment Resource Envelopes
– CARA Grant
Contact Information
– Amanda Tuura, RN, BSN
– (262) 605-6718
– Gianna Ventura, RN, BSN
– (262) 605-6736
