Local Progress on Addictionin Scioto County, Ohio

Lisa Roberts RN / Portsmouth City Health DepartmentDr. Darren Adams DO / Scioto County CoronerJone Stone BSN RNC-OB, / SOMC Maternity DepartmentDr. Michael Martin MD/ Scioto County Health CommissionerHon. Judge Alan Lemons/ Scioto County Probate Court

KY WV

OH

Overview and History of the Opioid Epidemic

Public Health Nurse Coordinator/ Drug-Free Communities Support Program Portsmouth City Health Department

Disclosures

The speaker and members of this presentation do not have a conflict of interest in this topic.

There is no commercial support for this program.

ObjectivesWe will:

Discuss the opioid epidemic and death rate in Scioto County, OhioExplain the programs and local responsesHighlight steps taken to decrease recurring opioid overdoses

Our Objectives are to:

Describe the addiction epidemic in a small rural community and how it is being addressed

Discuss programs developed in the juvenile court systemDiscuss local programs and intervention strategies for communities

Fatal Drug Overdose U.S. 2002-2014 A 14 year span…….

2002 2014

Ohio now has the highest number of fatal OD’s of all states.West Virginia maintains the highest rate.

OHIO Fatalities 2000-2014

OHIO Opiate Treatment 2001-2014

OHIO NAS Newborns 2004-2014

OHIOThe state of the state:

- 2015 #1 in number of deaths from accidental fatal OD- Total 3,050 deaths

Scioto County Data/ History and Risk Factors:

Risks:Appalachian-Distressed County; population 75,000Ohio’s original epicenter for opioid problems

2000- First cluster of “pain clinics” across the river (KY)2002- First pill mill established in Portsmouth (OH)By 2010- 12 illegitimate Pain Clinics had operated in Scioto County in a “family tree” fashion. Between 2002-2011 Home to a leading prescriber of oxycodone in the nation-three different times

2010: Scioto County saw 9.7M pain pills dispensed (123 pills/person)-Highest in Ohio

Results:Highest fatal OD 2010-2012 in stateHighest opioid addiction rate in OhioHighest rate of NASHighest rate of drug incarcerations in Ohio Huge increase in Hepatitis C rates-highest in Ohio

* In April 2011, DEA led raids on Scioto County Pain Clinics.

* Ohio HB93 “the Pill Mill Bill”passed as an Emergency Measure.Pain Management now regulated.

Scioto County organized: Key state and federal grants to address the problem

2010 “Prescription for Community Recovery” One of two counties funded by ODH BHPRR to reduce fatal overdose (state grant).

2012- HIDTA Designation by Congress (federal grant)

2012 “Project DAWN” Naloxone Pilot Project

2012 “Drug Free Communities Support Program” from the White House Office of National Drug Control Policy (federal grant)

These programs seeded a comprehensive sustainable community response to the opioid epidemic

Formed a Community Coalition

Use data to inform strategies, target high-risk populations, and issue Public Health Alerts

Implemented population-based programs designed to:

Prevent new initiates to opioid abuse• Community awareness • Created/Promoted safe and responsible prescribing of opioids through guidelines, training, and PMP enhancements• Alternatives to opioids for pain• Youth prevention initiatives

Treat the addicted and reduce harms associated with Opioid Use Disorders• Piloted Ohio’s first Community-Based Naloxone Program• Started a Syringe Exchange Program to reduce BBP diseases and link participants to recovery services• Expanded access to addiction treatment including Medication-Assisted Treatment• Expanded Drug Courts to provide oversight and improve addicted offender and family Outcomes

Progress: Scioto County- Opioid Consumption 2010-2016

15% decrease in opioids dispensed per capita

48% decrease inaverage Daily MED

per capita

Progress: Scioto County High School Surveys 2013-2016Non-Medical Use of Rx dropped in all grades declined across all grades

First Project DAWN Program established Scioto County in 2012.Since expanded to 48 programs in 35 Ohio counties. Naloxone use being expanded to non-traditional First Responders (LE, FD, lay savers.) Ohio has passed laws to increase and ease access 2016 Naloxone made available in select pharmacies through a medical protocol Good Samaritan Law passed to encourage 911 calls

Since 2012 hundreds of overdose reversals in SCIOTO COUNTY and thousands across Ohio

Naloxone for Overdose Reversal

State Public Awareness Campaign ODH/OhioMHAS

* 15 counties with highest fentanyl deaths got Billboards and statewide PSA’s* Pharmacies in Scioto County dispensing naloxone without a Rx are all CVS, Kroger

http://www.odh.ohio.gov/stopoverdoses

Scioto County Non-EMS Naloxone Administration 2012-2016

2012 2013 2014 2015 2016

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Scioto County, Ohio Naloxone Administrations Non-EMS 2012-2016

Top 220 US Counties for Hepatitis C Considered at risk for HIV Outbreaks-2015 Source: CDC

“Prevention NOT Permission” SEP at the Portsmouth City Health Department

There is much emphasis on SEP’s now, both federally and at the state level

Federal:

• CDC has endorsed SEP’s as an effective method to reduce the spread of BBP

• In 2015 Congress lifted the ban on funding for SEP

State:

• Effective Sept. 2015, Ohio Boards of Health can establish a “Blood borne Pathogen Prevention Program” without declaring an emergency

• PCHD hosts teams from other Health Departments to assist them in starting SEP’s.

State and Local Efforts:

• In 2016 the “Prevention NOT Permission” SEP exchanged 115,000 syringes

• The Prevention NOT Permission SEP functions as a GATEWAY to Healthcare, Immunization against Hepatitis A and B, early detection of Hepatitis C and HIV, and referral to Addiction Treatment.

Syringe Exchange Programs: The Evidence is SupportiveThe current opiate epidemic is directly related to rising rates of Hepatitis C,

Hepatitis B, and HIV

Syringe Exchange Programs have been associated with:

52% reduction in new cases of HIV;

65% reduction in new cases of Hepatitis C when combined with MAT ;

61% reduction in new cases of Hepatitis B;

Increased entry into substance abuse treatment and healthcare

Reduction of dangerous needles in public places

Cost effectiveness. Price of 1 syringe averages .50 cents

Cost of treating Hepatitis C $95,000

Cost of treating HIV $400,000

Progress: Scioto County New Cases of Acute Hepatitis C 2010-2016

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Scioto County New Acute Cases of Hepatitis C2010-2016

Live Surveillance of ED Visits: Early Warning EpiCenter ALERT: Scioto County Residents “Drug” Classifier Anomaly, November 5-6, 2015.Nov 1 spike was “highest to date” / Nov. 6, 2015 spike “highest in history”

Approx 350 people in 12 mo.Average 29/monthAverage age 32.7

CDC in Scioto County11-5-15

Scioto County has implemented EMS policies and Public Health notification for sudden spikes in OD (usually related to illicit Fentanyl)

“Fake” pills contain cheap illegally manufactured Fentanyl. Made to look like real pills.

Emergency Room Visits 2007-2016 Scioto County Actual Number as detected by EpiCenterElectronic Surveillance System

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

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Scioto County, Ohio Drug-Related ED Visits 2007-2016

August 31, 2016 IOAD Scioto County* Targeted Outreach in highest OD burden area (east Portsmouth)

ALS ADAMHS Board The Broken Need a Healing The Counseling Center Drug Free Communities Support Program HopeSource Mahajan Therapeutics PCHD Port45 Recovery Pike County Recovery Council Recovery Gateway SOLACE

Took 11 into Addiction Treatment that day

The “Troops”

The IOAD Memorial/Awareness March

IOAD Social Media Campaign #IOADScioto

Maternal Substance Abuse and Neonatal Impact

Nurse Manager, Maternity Southern Ohio Medical Center

Scioto County has the highest rate of newborns suffering from Neonatal Abstinence Syndrome (this is more than 8 X higher than the state average) Source: OhioMHAS

Neonatal abstinence syndrome(NAS; ICD-9 779.5) per 1,000 livebirths in Ohio by county of patientresidence. On average, there were8.8 discharges for NAS per 1,000

live births statewide between 2009and 2013. Counties with the

highest rates of NAS dischargeswere Scioto (76.0), Lawrence

(66.7) and Pike (57.7).

Maternal and Newborn History 2003-2009

Wrote our first Maternity policy on toxicology screening for mothers and newborns (2003)

Educated our Pediatricians and nursing staff on the Newborn Finnegan assessment tool for Neonatal Abstinence Syndrome (NAS) screening (2003)

Pediatricians started using morphine to withdraw newborns (2003)

Developed a defined role for Social Service and Scioto County Children’s Services

Started communication with Nationwide Children’s Hospital about NAS

Did not transfer newborns for withdrawal if that was their only diagnosis

Newborn toxicology screens were urine and meconium (2003)

Sought out as much education and information as we could find

It was challenging to know what was best for the patients

It was challenging to know how to interact with the families

Maternal and Newborn History (cont.) 2010

2010 Challenges:

Managing the parents and families in our unit

Having a reliable newborn specimen that parents had not discarded or tampered with

Knowing which mothers to screen

Managing a newborn length of stay for withdrawal inside a newborn nursery

Determining a therapeutic dose (Morphine: 0.08 for all newborns) and a weaning protocol that was not individualized by Pediatricians

Maternal and Newborn History (cont.)

Progress from 2010-2013:Worked with US Drug Testing Lab to implement umbilical cord testing

Established a SOMC Maternal Neonatal Substance Abuse Task ForceMembers: Dr. Adams, Dr. Turjoman, Social Service, OB, and ED.

Connected with Director of the Stepping Stones Program and set up Maternity Workgroup ( SS House Director, SOMC OB, Scioto County Children’s Service, Valley View Prenatal Clinic)

SOMC requested assistance from The Counseling Center to educate 100% of our Maternity Staff about addiction

Worked with our Coders on documentation/reimbursement issues for NAS

Obstetricians made a decision to do 100% screens on maternal admissions and outpatient triage (2011)

Quality Improvement Projects

Nationwide Children’s NAS Rural Collaborative (2013-2015)Between 2004-2008 NCH experienced a six fold increase in NAS admissions and had a LOS between 31-58 days

SOMC was invited to participate in this with four other hospitals (Marion, Adena, Licking, Genesis)

NCH Aim: to reduce the LOS by 25% by Sept. 2015

Interventions that occurred during the project:

Staff/Parent education on swaddling, kangaroo care

Volunteer Program

OT consult on all newborns started on morphine (SOMC OT went to NCH to train)

Educated our RN and OT staff on non pharmacological interventions

Quality Improvement Projects (cont.)

Ohio Perinatal Quality Collaborative (2014-2017) (funded by CMS) Team: Dr. Adams, Dr. Turjoman, Social Service, and OB

Participated with 50 hospitals in Ohio

Aim: Reduce variation in identification and treatment of NAS and standardize non pharmacologic and pharmacologic care practices

OPQC Hospitals LOS was at 19.3 when started in 2014 and 18.5 in 2016

Interventions:

Improve scoring with Finnegan Assessment (RN scoring accuracy)

Standardize pharmacological and non pharmacological bundles

Standardize nutrition (formula and calories)

Progress To Date

2017: Dual Finnegan Scoring *

Implementation of a Morphine Protocol dose based on newborn weight with initiation, escalation, stabilization, and weaning phases. *

Formula: Similac Sensitive 22 calorie*

Skin to Skin

On going protocols changes to support staff safety as they manage the families in our unit

* LOS decrease from 12.4 to 9.6 days

Percent of Positive Maternal Toxicology Screens

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12.0% 11.7%

10.5%

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Percent of Positive Neonatal Toxicology Screens

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Newborn Care: Percent of Newborns Screened for NAS

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% of Newborns Screened for NAS

(292) (295) (304)

(221)(262)

% of Newborns screened with Finnegan scoring and cord toxicology based on total birthsTotal Births: 2012: 1,174 2013: 1,229 2014:1,149 2015: 1,186 2016: 1,194

Newborn Care: NAS Newborns Treated Pharmacologically

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2011 2012 2013 2014 Jan-Jul 2015 Aug 2015-Dec 2016

Aug 2015 – Dec 2016: 9.6 LOS with Morphine Only

Future Considerations:

Maternal Buprenorphine prenatal weaning*

Is there a better place for NAS care other than inpatient Newborn Nurseries?

More research is needed to determine the best pediatric care and education needs of the opiate exposed newborn

*Newborn LOS decreased from 9.7 days to 5 days in weaned group

Scioto County Coroner

Unintended consequence of Ohio’s opioid crackdown…….* Heroin and illicit Fentanyl use and deaths increase

OHIOBetween 2010-2015 Rx Opioid deaths declined about 50%.......• Offset by enormous increases in• Fentanyl (825%) and Heroin (114%) fatalities

-50% +825%+114%

#1 Brown#2 Montgomery#3 Clermont#4 Butler#5 Adams

#6 Scioto#7 Clinton#8 Clark#9 Jefferson#10 Ross

OHIO Fatal Overdose 2010-2015

Progress: Scioto County # 6 after being #1 for a decade

Scioto County: 2015 there was a total 29 Accidental Overdose decedents• 100% involved multiple drugsAge groups:• Largest segment were 35-44 y/o (39%)• Second largest was 45-54 y/o (32%)

Scioto County, Ohio 2015 Accidental Fatal Overdose ILLICIT DRUGS detected by toxicology:• 72% were positive for heroin• 14% were positive for Methamphetamine

Scioto County, Ohio2015 Accidental Fatal Overdose Of Prescription Opioid mentions by toxicolgy:• 47% involved Morphine/Codeine• 21% involved Fentanyl• 14% involved Oxycodone• 10% involved Hydrocodone• No Buprenorphine or Methadone

Geographical Drug Fatality Map Scioto County , 2016

Autopsy Data, Scioto County 2016

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Fatal Overdose involving Opiates Scioto County, Ohio 2010-2016

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Scioto County Fatal Overdose with Opioid Involved 2010-2016 Source: Ohio Dept. of Health

Fatal Overdose: Ohio Versus Scioto County 2010-2015

Progress: Introduction of fentanyl has interfered with sustained progress in Scioto County but ……..to a lesser degree than the state as a whole.

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Scioto County Accidental Fatal OD2010-2015

36.3% Increase

Scioto County Health CommissionerMedical Director SOLACE, Inc. and Recovery Gateway

State Licensed AoD Treatment Program

SOLACE, Inc.

• Established 7-2015

• Out-patient Treatment Facility specializing in opioid addicted clients

• Provides Medications (Buprenorphine, Vivitrol) to clients along with counseling,

case-management, medical management, and other supportive services.

State Licensed AoD Treatment Program

Recovery Gateway:

• Housed within Portsmouth City Health Dept.

• State certified AoD Treatment Facility

• Based on “hub and spoke” model for HIV case management

• Serves as an access point for people seeking addiction treatment or other medical or social services

• Provides for a Field Case Manager to conduct outreach and follow-up on

complex cases for high-risk AoD clients (recent OD, active IV injectors, Probation, non-compliant with treatment)

• Collaborates with ED and Judicial Systems to inter-refer

• Refers OUT to appropriate levels of care when indicated

• Provides counseling and Vivitrol for relapse-prevention

Scioto County Court of Common PleasProbate- Juvenile DivisionFamily Reunification through Recovery Court

Scioto County has the highest rate of incarceration for drug offenses in Ohio (nearly six times the state average). Source: Ohio MHAS 2015

This map displays Ohio prison incarcerations for drugoffenses by committing county. A snapshot of the prison population on January 1, 2015showed there were 7,458 drug-related incarcerations witha statewide average rate of 6.4

incarcerations per 10,000 persons.Scioto (37.9), Highland (27.7) and Adams (27.4) counties hadthe highest drug-related

incarceration rates per 10,000 persons.

Scioto County Court of Common PleasProbate/ Juvenile Division

• In 2014, established a specialized docket to address the drug problem in families.

• “Family Reunification and Recovery Court” (FRRC) is Ohio Supreme Court Certified

• The purpose of the Family Reunification through Recovery Court is to more effectively deal with parents and caregivers who are addicted and unable to properly care for their children.

Progress: Community Support/ a strong Recovery CommunityOhio’s National March Against Heroin March 31, 2017

2,000 attended$1M in treatment scholarshipsFREE Event/ Raised $$ for NarcanCompletely conducted by Recovery Community