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Welcome&
Introduction
Charles Papp, M.D.President, Lexington Medical Society
Lexington Medical SocietyOpioid Symposium: Perspectives,
Connections, & Strategies for Action
October 16, 2019
LMS Opioid Symposium
Thank you to our sponsors
Beverly Games & Jesse Lawler
Karen McIntyre and Angela Coleman
John DeWeese & Mike Soares
Lexington Medical SocietyOpioid Symposium: Perspectives,
Connections, & Strategies for Action
The opioid crisis has grown to the point where it penetrates
all walks of life, all occupations, and is found in every
neighborhood. The Opioid Symposium will provide
physicians with tools and resources they can use in their
practices.
Objectives:
▪ Inform physicians & community leaders on:
▪ The background & scope of the opioid crisis in
Lexington
▪ Perspectives from organizations on the front lines of the
crisis
▪ Identify ways physicians and community leaders can
connect patients and community members to support
LMS Opioid Symposium
LMS Opioid Symposium
For CME credit:
• Sign-in
• Turn in a survey
LMS Opioid Symposium
P
A
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Catherine HinesSUD Education and Outreach Coordinator
Findhelpnowky.org
Mark Jorrisch, M.D., DFASAM Immediate Past President
Kentucky Society of Addiction Medicine
Michelle Lofwall, M.D., DFASAMProfessor of Behavioral Science & Psychiatry and Bell Alcohol & Addictions Chair at U.K.
Center on Drug & Alcohol Research.
Lou Anna Red CornFayette Commonwealth’s Attorney
Kraig Humbaugh, M.D., MPHCommissioner of Health
Lexington-Fayette County Health Department
Ryan Stanton, M.D.Emergency Medicine physician with Central Emergency Physicians at Baptist Health
Lexington & Chief Medical contributor for WKYT TV
Chad Traylor Battalion Chief, EMS
Danesh Mazloomdoost, M.D.Medical Director, Wellward Regenerative Medicine
Tuyen Tran, M.D., MBALMS Executive Board Chair
Owner and CEO, 2nd Chance
Andrea JamesCommunity Response Strategist for Mayor Linda Gorton
Charles Papp, M.D.President, LMS
LMS Opioid Symposium
5 4 3 2 1
Sponsors
Dinner
Buffet
P
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Community Resources
1. Health Department
2. Chrysalis House
3. Find Help Now KY.org
4. KORE (KY Opioid Response Effort)
5. Additional literature
LMS Opioid Symposium
▪ Please save your questions
for the panel at the end
▪ We have distributed
question cards at each
table
▪ Make sure you have
signed in and complete
the survey in order to
receive the CME credit
▪ Approved for a maximum of
2.5 hours of AMA PRA
Category 1 CME credits.
▪ Approved for a maximum of
2.5 hours HB1 credits
Mayor’s Vision
Andrea James
Special Projects Coordinator, Mayor’s Office
LMS Opioid Symposium
Andrea James serves as Community Response Strategist for Mayor Linda
Gorton. Her emphasis is on the opioid crisis and its impact on the City of
Lexington. She served on Lexington’s city council 2007-2011 representing the
First District and has the distinct honor of being the first black woman to
serve as an elected city council member in Lexington. Andrea has worked in
local government, philanthropy and various medical administrative roles.
Outside of her work with Mayor Gorton, she is co-owner of S & A Strategies, a
consulting firm specializing in intentional inclusion and equity.
Personal Reflections
Melissa Combs
LMS Opioid Symposium
Setting the Stage of the Opioid Crisis
Tuyen Tran, M.D., MBA
LMS Opioid Symposium
Tuyen Tran, M.D. emigrated from South Vietnam after the war. He
completed his undergraduate in biology/chemistry and medical
school at the University of Missouri – Kansas City in a six-year
program. He is currently boarded in internal medicine and
addiction medicine.
OPIOID EPIDEMICKENTUCKY UPDATE
Tuyen T. Tran, MD, MBA
DISCLOSURES – NONE
• Tuyen T. Tran, MD, MBA
• Partner and CEO
• 2nd Chance – Addiction Treatment Center
OUTLINE
• How did we get here?
• Updates – Kentucky data
• Impact of opioid epidemic
Chronic Pain – 20th Century
• We still do not quite understand chronic pain
• AND we still do not have great treatment options for chronic pain
• Physicians OVERPRESCRIBE opioids
• But, physicians also overprescribe diagnostic evaluations, labs, imaging studies and antibiotics!!
• Physicians do not want to miss a diagnosis which could harm patients
• Physicians do not want patients to experience pain
Factors Contributing to the Opioid Epidemic
• Physician overprescribing of opioids
– Leftover pills are the problem
• “pill mills”
– Dr. David Proctor, the “Godfather of Pill Mills”
– 1992-2001, America’s first “pill mill” in South Shore, KY
• Cultural change regarding opioids and pain
– Too many patients are suffering unnecessarily because of inadequate pain management
– Physicians needed education to dispel the concern for addiction
– Insurances were not reimbursing for non-pharmacologic modalities for the treatment of chronic pain
Cultural Changes Regarding Pain and Opioids
• 1980 NEJM one paragraph letter: Jane Porter and Hershel Jick, MD– Retrospective review of 11,882 hospitalized patients who received narcotics
– Four patients were found to have “well documented addiction”
• 1986 PAIN Doctors Kathleen Foley and Russel Portenoy– Iatrogenic risk was low in 38 chronic non-cancer pain patients treated with
opioids
• 1995 Dr. James Campbell, president of American Pain Society, promoted “Pain is the Fifth Vital Sign”
• 1998 VHA incorporated pain as the “fifth vital sign”
• JCAHO (Joint Commission on Accreditation of Healthcare Organizations) embraced the “Pain is the Fifth Vital Sign”
• JCAHO issued standards requiring the use of a pain scale and treatment of pain, especially with opioids
Regulatory and Cultural Pressures
• JCAHO referred to pain management as a patient’s rights issue
– Inferred sanctions if pain was inadequately controlled
• 1985 Press Ganey, a survey of patients’ hospital experiences
– Collection of patient data was necessary for improvement
– Distinction between patient satisfaction and quality of care BLURRED
• CMS (Centers for Medicare and Medicaid Services) developed the value-based purchasing program
– Patient experience collected via HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
– “Did hospital staff do everything they could to help you with your pain?”
Pressure on Physicians to Prescribe Opioids
• Reimbursement to hospitals were tied to patient satisfaction
• Hospitals coerced physicians (via withholding payment or bonuses)
– CMS only required 300 surveys in a 12-month period
– Only a small number of patients actually completed the surveys
– A single poor survey could significantly impact whether the hospital achieved the required 90% percentile goal of patient satisfaction
– Thus, every patient must be satisfied!
• When patients requested/demanded opioid pain medications, physicians were often compelled to satisfy the patients, despite their reservations about the need for opioids
Kentucky Update - 2017
• Drug overdose deaths in the Commonwealth ranked 4th highest among the 50 states
• 1,565 Kentuckians died from a drug overdose (UP 11.5% from 2016)– Largest demographic: 35-44 y/o
– Heroin: 22% of OD (DOWN from 34% in 2016)
– Fentanyl: 52% of OD (UP from 47% in 2016)
• Largest increase in OD were in counties: Jefferson, Fayette, Campbell, and Kenton
• Largest decrease in OD were in counties: Madison, Bell, Knox, Breathitt, and Scott
• Perspectives: 2017– 782 died in traffic accidents
– 263 people were murdered
Impact on Families and Children
• Stress
• Financial strains
• Employment
• Relationships
• Co-dependency
• Criminal justice system
• Neonatal Abstinence Syndrome (NAS)
– CDC: KY had 3rd highest rate of opioid use at delivery among the 50 states
Impact on Criminal Justice System
• Offenders imprisoned for drug offenses– 2000: 30%– 2009: 38%
• Offenders sent to state prison for drug possession doubled from 2012 to 2016
• Offenders imprisoned for drug trafficking– 2012: 1,525– 2016: 1,916 (25% increase)
• Offenders jailed for drug possession– 2012: 911– 2016: 1836
• Current cost to incarcerate a state inmate in KY: $18,406 per year• About 4,500 additional inmates (drug offenses) costed KY in 2016:
$82M
Impact on the Workforce
• Alan Krueger, Princeton economist, published 2016
– Strong link between RISING opioid prescriptions and DECLINING workforce participation rates (percentage of people employed or looking for work)
– Half of men aged 25-54 who are not in the workforce take pain medication daily
• 2018 Research by Federal Reserve Bank of Cleveland
– Workforce participation rate was 4.6% LESS on average in counties with high rates of opioid prescribing
Impact on Kentucky Workforce
• 2017 report by Kentucky Chamber of Commerce
– Kentucky had one of the lowest workforce participation rates in the country
– Contributing factors:
• High levels of disability
• High levels of poverty
• High levels of incarceration
• Low education attainment
• High levels of substance abuse
• Kentucky employers cannot fill available jobs!
Community Collaboration
• Engage business leaders to discuss the opioid problem
• Increase public education
• Support efforts to hire people in recovery
• Reclassify drug possession as a misdemeanor
– Reduce number of offenders going to jail for drug possession
– Remove barriers to people in recovery from acquiring employment
Heal Pain
Danesh Mazloomdoost, M.D.
LMS Opioid Symposium
Danesh Mazloomdoost, MD is a Johns Hopkins & MD Anderson trained
anesthesiologist, pain, and regenerative specialist. As an international
speaker, author, and advocate for reform in pain management, Dr. Danesh
consults with private and governmental organizations to develop protocols
for pain that minimize opioid dependency, improve patient satisfaction and
health outcomes. His new book, Fifty Shades of Pain: How to Cheat on your
Surgeon with a Drugfree Affair has become an Amazon international best-
seller in ten categories. He is now the Medical Director of Wellward
Regenerative Medicine in Lexington Kentucky, the flagship for a new and
sustainable approach to managing pain while avoiding drugs or surgery.
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Acute Opioid ResponseR
x -
Op
ioid
Time
Pain
In
ten
sity
Opioid effect on pain score
Pain Generator
Rx
-O
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Rx
-O
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id
Rebound
Mauermann et al. Anesthesiology 2016 Feb;124(2):453-63
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6) Acute pain < 3days
• Acute pain course < 3 days
24-72hrs
1-3 wks
Resolve
• > 7 days rare and often reflects
undiagnosed pathology
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Onset of Dependency
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.
Long-term use > 1 year
• 6% for >1 day
• 13.5% >8 days
• 29.9% >31 days
(7% of all Rx)
Chronic Use risk spikes at 3 days
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Rx
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Rx - Opioid Rx - Opioid
Time
Pain
In
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Rx - Opioid
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Physiologic Pain
Opioid Pain
Op
ioid
s
walk on a broken leg
6.5% becomeopioid
dependentBrummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. Published online April 12, 2017
Opioid-naïve patientsundergoing surgery
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MessengeragePain ≠ DiseasePain = Disease
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Dissecting Pain
PAINNervesTissue
Injury
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Biomedical
(Regenerative)
Kinesthetic
(Functional
Movements)
Psychological
(Behavior &
Lifestyle)
Primary Care for
Pain
heal
HEAL
ear
nvision
lleviate
everage
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Pain Mapping
Hearing…
precision
accuracy
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Envisioning…
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Alleviating…
• Desensitization• Somatic Blocks• Autonomic Blocks• Neuroablation
• Neural Modulation• Dorsal Column• Peripheral Nerve
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Leverage…
Cellular Healing
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Healing Cycle
Injury
Inflammation
Proliferation
Regeneration
Rehabilitation
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Injury
Järvinen et al Muscles, Ligaments and Tendons Journal 2013; 3 (4): 337-345
InjuryInflamma
tion
Proliferation
Regeneration
Rehabilitation
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Inflammation
Injury
Inflammation
Proliferation
Regeneration
Rehabilitation
Hea
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Proliferation
Injury
Inflammation
Proliferation
Regeneration
Rehabilitation
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Regeneration
Injury
Inflammation
Proliferation
Regeneration
Rehabilitation
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Rehabilitation
Injury
Inflammation
Proliferation
Regeneration
Rehabilitation
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Cellular Healing
Leverage…
• Prolotherapy: Chemical-induction
• Autologous growth factors: PRP, PL, PR
• Allogenic growth factors:placental & amniotic derivatives
• Xenogenic tissue matrices
• Mesenchymal Cells, SVF, CFUs
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Regenerative Outcomes:WHO WILL HEAL FASTER?
optimize
First Responders
Battalion Chief Chad Traylor
LMS Opioid Symposium
Joined the Lexington Fire Department in 2003. Began career assigned
to a fire engine and after completing paramedic training transferred
to an ambulance. Throughout the years has held the assignments of a
Company Officer, Hazardous Material Team Leader, District Major,
Special Operations Commander and is currently the EMS Battalion
Chief.
Emergency Physician
Ryan Stanton, M.D.
LMS Opioid Symposium
EM doc with Central Emergency Physicians at Baptist Health Lexington.
Chief Medical contributor for WKYT TV and producer of “The Doc Is In”,
the weekly heath segment airing in 6 TV markets throughout the
southeast. Medical Director for Lexington Fire/EMS and on track traveling
physician for the AMR/NASCAR Safety Team. National Spokesperson for
the American College of Emergency Physicians and producer of the ACEP
Frontline Podcast. Dr. Stanton has been speaking around the country
regarding opioids for the past 10+ years and is currently involved with the
KHA SOS initiative.
Health Department
Kraig Humbaugh, M.D.
LMS Opioid Symposium
As Commissioner of Health, Kraig E. Humbaugh, MD, MPH is the chief
executive officer and medical director for the Lexington-Fayette County
Health Department. He is a board-certified pediatrician who has practiced
medicine for over twenty-five years in community, academic and public
health settings. Dr. Humbaugh earned his undergraduate degree from
Vanderbilt University, studied as a Fulbright Scholar at the University of
Otago in New Zealand, and received his medical degree from Yale University.
He holds a Master of Public Health degree from Johns Hopkins University.
Reducing Harm Among People who
Inject Drugs
Lexington Medical Society’s Opioid Symposium
October 16, 2019
Kraig E. Humbaugh, MD, MPH
Commissioner, Lexington-Fayette County Health Department
WHAT IS A NEEDLE EXCHANGE?
65
▪A public health program designed to reduce the negative health consequences of injection drug use: “Meeting people where they are.”▪ Provides new, sterile needles and syringes▪ Provides safe disposal site for contaminated needles
and syringes
▪Needle exchange programs are proven to reduce the spread of HIV, hepatitis C, and other blood-borne infections, without leading to increased drug use in communities. They can decrease needle stick injuries.
▪Under Kentucky law, only health departments can operate needle exchange programs.
Logistics of Lexington’s Exchange
• When: Mondays 1-4 PM; Wednesdays 3-6:30 PM; Fridays 11 AM-4 PM
• Where: Lexington-Fayette Co HD: 650 Newtown Pike
• What: Free, anonymous, modified needs–based needle exchange
• Uses trained health department employees who often have other “day jobs” at the health department
• Cost to agency: about $500,000 per year. Compare to lifetime cost of one new case of HIV (>$350,000)or cost of treating one case of hepatitis C ($30,000-$50,000)
MONTHLY VISITS TO NEEDLE EXCHANGE PROGRAM:28,228 Visits by 5,059 ClientsSeptember 4, 2015 – September 6, 2019
67
82%42%39%24%43%39%39%21%25%17%31%38%
34%32%28%21%24%23%23%21%19%15%13%14%14%13%16%16%
13%15%13%15%11%13%12%9% 8% 9%12%9%10%10%8% 8% 7%10%7% 7%18%58%61%76%57%61%61%79%
75%83%
69%
62%
66%68%72%
79%
76%77%
77%
79%81%
85%
87%86%
86%
87%84%
84%
87%
85%
87%
85%89%
87%
88%
91%
92%
91%88%
91%
90%90%92%
92%
93%
90%93%
93%
0
200
400
600
800
1000
1200
1400
Sep
'15
Oct
No
v
Dec
Jan
'16
Feb
Mar
Ap
r
May Jun
Jul
Au
g
Sep
t
Oct
No
v
Dec
Jan
'17
Feb
Mar
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r
May Jun
Jul
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Sep
Oct
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Dec
Jan
'18
Feb
Mar
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May Jun
Jul
Au
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Sep
t
Oct
No
v
Dec
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'19
Feb
Mar
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r
May Jun
July
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First Visit Repeat Visit
AGE DISTRIBUTION OF NEEDLE EXCHANGE PROGRAM CLIENTS (n=5024)September 4, 2015 – September 6, 2019
68
REPORTED DRUG OF CURRENT USEAT CLIENT ENCOUNTER
September 4, 2015 – September 6, 2019
73%
21%
2% 2% 2%
Heroin
Methamphetamine
Suboxone
Oxycodone
Cocaine
SELF-REPORTED FIRST TIME CLIENT PARTICIPATION IN TREATMENT/RECOVERY PROGRAMS
March 3, 2018 – September 6, 2019
PAST PARTICIPATION IN A
TREATMENT/RECOVERY PROGRAM
(n =1515)
NUMBER OF TIMES IN
TREATMENT/RECOVERY PROGRAM
(n=988)
TOTAL NEEDLES RECEIVED & DISTRIBUTED,LFCHD NEEDLE EXCHANGE PROGRAM
71
Total Number of Needles Received
September 4, 2015-September 6,
2019
Total Number of Needles Distributed
September 4, 2015-September 6,
2019
943,506 1,152,346
Ratio of needles received to needles distributed:
0.82 : 1
Other Harm Reduction Strategies
• Needle exchange is one part of a comprehensive harm reduction plan.
• Additional services offered on-site at the exchange through partnerships with community partners, under a confidential, medical/provider model:
• rapid HIV and hepatitis C testing (with AVOL)
• hepatitis A and B vaccination
• referrals to counseling and treatment (with LFUCG, New Vista, Chrysalis House)- over 200
• naloxone training and distribution (with LFUCG)
Naloxone Distribution
73
• As of September 6, 2019, 2976 naloxone kits have been distributed for use in the community setting.
• Training is done by health department nurses and takes about 15-20 minutes total.
• Participants are taught how to recognize an overdose, how to administer naloxone nasal spray and to call emergency medical services
• More trainings, including community events, are planned.
• A media campaign is being developed to encourage people to carry and use naloxone when needed.
Kraig Humbaugh, MD, MPH
Commissioner of HealthLexington-Fayette County Health Department
County Prosecutor
Lou Anna Red Corn
Fayette Commonwealth’s Attorney
LMS Opioid Symposium
Lou Anna Red Corn was appointed Fayette Commonwealth’s Attorney
in 2016, and elected to the position in 2018. She has been a
prosecutor in the office since 1987. Lou Anna serves the state’s
prosecutors as treasurer and Best Practice Committee Co-Chair of the
Commonwealth Attorney’s Association, she is the current state’s
representative to the National District Attorneys Association and the
nation’s prosecutor representative on the National Children’s Alliance
Board of Directors, the organization that accredits the country’s
Children Advocacy Centers.
HEAL Program
Michelle Lofwall, M.D.
LMS Opioid Symposium
Michelle Lofwall MD is a Professor of Behavioural Science and Psychiatry and
the Bell Alcohol and Addictions Chair at the University of Kentucky Center on
Drug and Alcohol Research. She is the medical director of the First Bridge
outpatient opioid use disorder (OUD) treatment clinic that provides
comprehensive care to patients discharging from the emergency room and
inpatient medical/surgical services. Her clinical research has been funded by
the National Institutes of Health and industry with a focus on OUD. She was
as an expert panel member on SAMHSA’s newly published Substance
Treatment Improvement Protocol (TIP 63) for Medication Treatment of OUD,
a board member of the American Society of Addiction Medicine, an invited
speaker to the National Academy of Medicine and recipient of several
medical student teaching and mentorship awards.
7777
NIH HEALING COMMUNITIES STUDY UPDATE
MICHELLE LOFWALL, MDPROFESSOR
COLLEGE OF MEDICINE
CENTER ON DRUG AND ALCOHOL RESEARCH
78
SUBSTANCE USE RESEARCH AT UK
• The University of Kentucky has established 6 research priority
areas, which grew out of a 2014 Board of Trustees Retreat.
These highlight a focus on research where:
• The needs of Kentuckians and the Commonwealth are most
pressing; and,
• The University can continue to compete successfully for
external research support.
(see: https://www.research.uky.edu/research-priorities-initiative)
• The UK Substance Use Priority Research Area (SUPRA) mission
is to prevent and reduce the burden of substance use disorder
(SUD) through conducting and translating multidisciplinary and
innovative research to inform clinical services, training, public
health practice and policy.
79
A partnership with the National Institutes of Health (NIH), the
National Institute on Drug Abuse (NIDA), and the Substance Abuse
and Mental Health Services Administration (SAMHSA)
The funding announcement required specific evidence-based
prevention and treatment interventions, including: prevention
efforts related to opioid overdose; screening and assessment of
opioid misuse and OUD; linkages and engagement in treatment;
use of medications to treat OUD; and ongoing recovery support
services. Integrated evidence-based interventions will be delivered
in multiple settings and are required to include healthcare,
behavioral health, and justice settings.
THE HEALING COMMUNITIES STUDY
80
The primary aim is to develop an evidence-based integrated
strategy to reduce opioid-related overdose deaths by 40% in three
years in at least 15 highly affected communities by:
➢ Increasing distribution of naloxone (Narcan)
➢ Increasing the number of individuals receiving medication
treatment for opioid use disorder
➢ Increasing retention of people in treatment beyond 6 months
➢ Increasing the number of people receiving recovery support
services
THE HEALING COMMUNITIES STUDY
81
THE HEALING COMMUNITIES STUDY
$87 million was awarded to the University of Kentucky (one of four
states to receive the award). Massachusetts, New York, and Ohio
were also awarded.
Our project is being conducted in partnership with numerous federal,
state, community, public health, criminal justice, behavioral health,
and health care partners.
HEALing Communities Study – Kentucky is led by Dr. Sharon Walsh,
Director of the UK Center on Drug and Alcohol Research
HCS Sites
Massachusetts New York
Ohio Kentucky
Rural Urban
COUNTY SELECTION FOR HEALING COMMUNITIES: KENTUCKY
83
County Selection and How Data was used to Inform Design
120
48
35
28
25
19
16
Counties in Kentucky
Counties with ≥ 25 opioid overdose deaths per 100,000 residents
in 2017
Counties without ‘suppressed data’ (i.e., ≥ 5 opioid
overdose deaths)
Counties with justice infrastructure (i.e., jails)
Counties with treatment infrastructure (i.e., ≥ 1
provider licensed to prescribe medication)
Counties with public health infrastructure
(i.e., SSP)
Counties not already involved in a
major UK intervention project
The served area
encompasses over
1.8 million people
(approximately 41% of the
state’s population).
48 counties with > 25 opioid overdose deaths per 100k in 2017
HEALING COMMUNITIES: KENTUCKY
84
Projects were required to target at least 15 counties or
cities highly affected by overdose, defined as:
➢ A rate of 25 opioid related overdose deaths per 100,000
persons or higher in the past year
➢ The Kentucky HEALing Communities counties had an
average rate of 45.7 opioid-related overdose deaths per
100,000.
➢ Combined total of at least 150 opioid-related overdose fatalities
➢ The Kentucky HEALing Communities counties had a total
764 opioid-related overdose deaths in 2017.
➢ 30% of the counties/cities must be rural
➢ 44% of Kentucky HEALing Communities counties are rural
HEALING COMMUNITIES: KENTUCKY
85
Expand access to overdose-
reversing naloxone
Link people leaving
jail and on
probation/parole to
treatment and
naloxone
Link clients of harm
reduction programs
to treatment and
naloxone
Reduce high-risk prescribing and
increase safe disposal of medications
Reduce barriers to
medication treatment
and improve
retention in care
Provide peer support
services to help
people through
recovery
The project will be guided by local community coalitions and the
following potential strategies:
86
➢ Every county in the project will receive a “Care Team”
➢ Communities will be engaged in a communication
campaign to reduce stigma and improve awareness of
services
THE HEALING COMMUNITIES STUDY: KENTUCKY
CARE TEAMS
Community Coordinator
Syringe Service Program
Prevention Specialist
Treatment Care Navigator
Jail Care Navigator
Probation and Parole
Prevention Specialist
Local coalition (ASAP Board)
87
Train-the-trainer overdose education
and naloxone training for local health
department staff, local pharmacists,
and first responders
Rigorous evaluation of what works
and what does not work could inform
intervention rollout for other parts of
the state
Detailed cost-effectiveness analysis
will be shared with policy-makers at
the state and local level so that they
can consider it in future program
funding decisions
THE HEALING COMMUNITIES STUDY: KENTUCKY
SUSTAINABILITY
Where to Get Help, MAT, Psychotherapy
Mark Jorrisch, M.D., DFASAM
LMS Opioid Symposium
Immediate Past President of KYSAM, distinguished Fellow of ABAM, Board
Certified Internal Medicine and Addiction Medicine, practice at BHG
Lexington, an OTP offering both methadone and buprenorphine, and at the
MORE Center in Louisville, an OTP offering methadone.
Mark Jorrisch MD DFASAMMethadone Maintenance
Treatment
No disclosures
Heroin and the Reward Pathway
Heroin
(di-acetyl-morphine)
very lipophilic
rapidly crosses the blood brain barrier in the Reward Pathway
This is the reason
heroin is preferred
over morphine
by injection
opioid users
Wit
hd
raw
alN
orm
alE
up
ho
ria
Chronic useInitial use
Tolerance & Physical Dependence
Alford DP. http://www.bumc.bu.edu/care/
Development of Substance Use Disorders Involves Multiple Factors
Substance Use Disorder
Biology (Genes/Development)
Environment
Drug / Alcohol Use
Brain Mechanisms
Reward & Reinforcement is… Ventral
Tegmental Area (VTA)
Nucleus Accumbenswith projections to Prefrontal Cortex
Dopaminergic system
...in part controlled by mu receptors in the Reward Pathway
Leshner AI. Hosp Pract. 1996
Longitudinal Trends in Recovery
36%
66%
86% 86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 to 12 months(n=157; OR=1.0)
1 to 3 years(n=138; OR=3.4)
3 to 5 years(n=59; OR=11.2)
5+ years(n=96; OR=11.2)
% S
ust
ain
ing
Ab
stin
ence
Th
rou
gh Y
ear
8
Duration of Abstinence at Year 7
After 5 years <15%
relapseIt takes a year of abstinence before
<50% relapse
Dennis ML et al. Eval. Rev. 2007
Medically Supervised Withdrawal Management (“Detox”)Low rates of retention in treatment
High rates of relapse post-treatment
< 50% abstinent at 6 months
< 15% abstinent at 12 months
Increased rates of overdose due to decreased tolerance
O’Connor PG. JAMA. 2005. Mattick RP, Hall WD. Lancet. 1996.Stimmel B et al. JAMA. 1977.
Medications to Treat Opioid Use Disorders
GoalsAlleviate signs/symptoms of
physical withdrawal
Opioid receptor blockade
Diminish and alleviate drug craving
Normalize and stabilize perturbed brain neurochemistry
OptionsOpioid Antagonist
Naltrexone (full antagonist)
Opioid Agonist
Methadone (full agonist)
Buprenorphine (partial agonist)
Naltrexone
Mu-opioid receptor antagonist
Not a controlled substance, no special prescribing restrictions
Patients physically dependent must be opioid free for a minimum of 7-10 days before
treatment
Also FDA approved for the treatment of alcohol use disorders
Oral naltrexone (generic and brand Revia)
Well tolerated
Duration of action 24-48 hours
FDA approved 1984
IM injection extended- release naltrexone (Vivitrol)
IM injection (w/ customized needle) once/month
FDA approved 2010
Naltrexone SummaryB
en
efit
s
Good for patients who do not want opioid agonist therapy
No risk of diversion (not a controlled substance)
No risk of overdose by drug itself
Can be administered in any setting (office-based or OTP)
Long-acting formulation
Treats both opioid use disorder and alcohol use disorder
Lim
itat
ion
s
Difficulty starting—must be fully withdrawn from opioid; > short-acting (6 days); long-acting opioids (7-10 days)
Not recommended for pregnant women. Pregnant women who are physically dependent on opioids should receive treatment using methadone or buprenorphine
Not suitable for patients with severe liver disease
Loss of tolerance to opioids increases the risk of overdose if relapse occurs
Kampman, K. et al. (2015). The ASAM National Practice Guideline
Methadone Hydrochloride
Full opioid agonist Oral: 80-90% bioavailability liquid, tablet, and disket formulations
Duration of action
24-36 hours to treat OUD
6-8 hours to treat pain
Proper dosing for OUD
20-40 mg for acute withdrawal
> 80 mg for craving, “opioid blockade”
Can be administered parenterally (IV, SQ or IM)
at 80% of the total daily oral dose administered in a divided dose every 12 hours (e.g., 40 mg by mouth every day = 16 mg IV every 12 hours)
Mercadante S. (2013) Handbook of Methadone Prescribing and Buprenorphine Therapy.
Methadone Maintenance in OTP
Highly structured
Methadone dosing
Daily nursing assessment
Weekly individual and/or group counseling
Random supervised drug testing
Psychiatric services
Medical services
Observed daily → “Take homes” based on stability and time in treatment. Max: 27 take homes. Varies by state, county and individual clinics
Methadone Summary: Benefits
Increases overall survival
Increases treatment retention
Decreases illicit opioid use
Decreases hepatitis and
HIV seroconversion
Decreases criminal activity
Increases employment
Improves birth outcomes
Joseph et al. Mt Sinai J Med. 2000;67:347-364.
Methadone Summary: Limitations
Highly regulated: Narcotic Addict Treatment Act 1974
Created methadone clinics (Opioid Treatment Programs)
Separate system not involving primary care or pharmacies
Limited access InconvenientMixes stable and unstable patients
Lack of privacyNo ability to
“graduate” from program
Stigma: “Methadone is substituting one drug for another…I don’t
believe in methadone”
Buprenorphine
Semi-synthetic analogue of
thebaine
Approved by the FDA in 2002 as Schedule III
— up to 5 refills
High receptor affinity
Slow dissociation
Ceiling effect for respiratory depression
Partial Mu-opioid agonist , k
antagonist
Buprenorphine Efficacy: Summary
Studies (RCT) show buprenorphine (16-24 mg) more effective than placebo and equally effective to moderate doses (80 mg) of methadone on primary outcomes of:
Retention in treatment
Abstinence from illicit opioid use
Decreased opioid craving
Decreased mortality
Improved occupational stability
Improved psychosocial outcomesJohnson et al. NEJM 2000; Fudala PJ et al. NEJM 2003; Kakko J et al. Lancet 2003; Sordo L et al. BMJ 2017; Mattick RP et al. Conchrane Syst Rev 2014; Parran TV et al. Drug Alcohol Depend 2010
There Remains Limited Access to Evidence-Based, Long-Term, Life-Sustaining Treatment with Medications for Patients Seeking OUD Treatment
Guidelines for the Behavioral Treatment as Part of Medication-Based OUD Treatment (WHO 2009)
Psychological support should be offered routinely in association
medications for OUD
Treatment services should aim to offer onsite, integrated,
comprehensive psychosocial support to every patient
While patients should be offered psychosocial support, they should not be denied medication should they refuse such support, but encouragement to utilize psychosocial
support should be continued
12 Step Oriented Treatment Self-help Groups
Group Therapy Supportive Psychotherapy
Cognitive Behavioral Contingency Management
Cue Exposure Psychodynamic
Network Therapy Community-Based Model
Couple or Family Vocational Training
Motivational Enhancement Relapse Prevention
106
Treatment Interventions
PCSS
Pill counts
Pharmacy collaboration
State prescription monitoring reports
Urine drug tests
Psychosocial & behavioral treatments
Appropriate prescribing practices
Therapeutic doctor-patient relationship
Many Layers of SUD Practice
107
Find Help Now KY.orgCatherine Hines
Coordinator, KY Injury Prevention & Research Center at U.K.
LMS Opioid Symposium
Catherine Hines is the Education and Outreach Coordinator for
findhelpnowky.org, Kentucky Injury Prevention and Research Center’s
treatment locator website. She holds her BA in Classical Studies from Centre
College. Catherine currently works with treatment facilities to ensure they
update essential information onto the website as needed. She also reaches
out to new treatment centers in an attempt to onboard them to the website.
She works with the FindHelpNowKY team in the process of managing interest
from other states which may implement this website for their own
communities. Since her interest lies in education, she is working on
researching and making connections with Universities and Colleges
throughout the state in an attempt to educate them on the website and its
use.
Catherine Hines, SUD Education and Outreach Coordinator
Kentucky Injury Prevention and Research Center
Bona fide agent of the Kentucky Department for Public Health
University of Kentucky, College of Public Health
A Valuable Tool in the Fight Against Addiction
FindHelpNowKy.org
Project Overview
Application in Healthcare Setting
Website Demonstration
State of Treatment in KY
FindHelpNowKy.org
What is it?
Dynamic near-real-time substance use disorder
(SUD) treatment locator and information repository
Valuable tool for healthcare professionals, public
safety officials, and the general public
Unprecedented inter-cabinet collaboration in
response to the opioid and overdose crisis in KY
Resource for research and insights into the state of
SUD treatment in KY
FindHelpNowKy.org
Project Overview
Funded for 2016-2019 by Centers for Disease
Control and Prevention (CDC)
National Center for Injury Prevention and Control
Prevention for States (PfS) grant
Funded for 2019-2022 by Centers for Disease
Control and Prevention (CDC)
Overdose Data to Action (OD2A) Grant
Partnerships
Project Team
Terry Bunn, PhD
KIPRC Director
Dana Quesinberry, JD
Principle Investigator
Jodie Weber
Program ManagerCatherine Hines
SUD Education and
Outreach Coordinator
Tyler Jennings
Technical and Marketing
Coordinator
FindHelpNowKY.org
Development Goals
Quick and easy search to facilitate rapid access to
treatment
Near-real-time information on availability of treatment slots
Advanced filters to meet specific needs
Resource library, including one pagers on SUD topics
1-833-8KY-HELP helpline prominently displayed
Dynamic analytics to facilitate research and track state of
treatment in KY
Broad compatibility
FindHelpNowKY.org
Development Outputs
Fully designed and tested front- and back-end environments
Management interface to track provider engagement
28 one-page documents on variety of SUD topics
Informational brochures
Pocket cards
Instructional videos for public and providers
Healthcare provider-patient SUD communication guide
FindHelpNowKY.org
Treatment Provider Stats
Currently indexing over 600 KY treatment facilities
Approximately 90% of licensed AODE/BHSO treatment facilities
Over 50 MAT DATA Waivered physicians on board
Approximately 10% of MAT Data Waivered physicians in the state
Difficult to reach and engage population
Over 100 data points captured for each facility
From total treatment slots to tobacco use and gender-based bed
assignment policies
FindHelpNowKY.org
Application in Healthcare
Massive reduction in time to find available treatment options
Get a list of facilities with openings and sorted by distance in about 20 seconds. More specific results in a little over a minute.
Quickly find and share resources with patients or their loved ones
Use filters and text search to rapidly narrow list of resources
Match unique patient needs to treatment providers
Filters for demographic info, comorbidity, additional services, payment methods, etc…
Enhances SBIRT or related processes
Easily fits in to SBIRT intervention and referral steps
Healthcare provider communication guide created by KIPRC augments SBIRT with stages of change model
FindHelpNowKY.org
Stats to Date
Since soft launch in Jan 15, 2018:
608 total facilities (~90% of licensed treatment facilities; ~10% of MAT
providers in state)
Over 242,000 unique visitors, 353,000 total visits, 606,000 total pageviews
Roughly 50% male, 50% female
Over 115,000 searches (41% concerned family, 35% healthcare
professional, 24% individual)
Providers have logged in over 8,000 times to view or update their profiles
Currently working on bringing the FindHelpNowKY platform to four
additional states
FindHelpNowKY.org
Average Visitor
First time visitor to the site
Male
Aged 25-44
From Jefferson County or surrounding area
Searching on behalf of a friend or family member
Looking for residential/inpatient treatment that accepts a form of Medicaid
MAT is a close second
Spends about 6 and a half minutes searching for facilities
FindHelpNowKY.org
State of Treatment
Source: Data gathered 06/21/2019 from FindHelpNowKY.orgSource: Data gathered 06/21/2019 from FindHelpNowKY.org and Google Analytics
327
190
201
58
93
12
0 100 200 300 400
OP
IOP
MAT
Detox
Reside…
Inpatie…
Treatment Options by Treatment Type
Total Facilities
LMS Opioid Symposium
P
A
N
E
L
Catherine HinesSUD Education and Outreach Coordinator
Findhelpnowky.org
Mark Jorrisch, M.D., DFASAM Immediate Past President
Kentucky Society of Addiction Medicine
Michelle Lofwall, M.D., DFASAMProfessor of Behavioral Science & Psychiatry and Bell Alcohol & Addictions Chair at U.K.
Center on Drug & Alcohol Research.
Lou Anna Red CornFayette Commonwealth’s Attorney
Kraig Humbaugh, M.D., MPHCommissioner of Health
Lexington-Fayette County Health Department
Ryan Stanton, M.D.Emergency Medicine physician with Central Emergency Physicians at Baptist Health
Lexington & Chief Medical contributor for WKYT TV
Chad Traylor Battalion Chief, EMS
Danesh Mazloomdoost, M.D.Medical Director, Wellward Regenerative Medicine
Tuyen Tran, M.D., MBALMS Executive Board Chair
Owner and CEO, 2nd Chance
Andrea JamesCommunity Response Strategist for Mayor Linda Gorton
Charles Papp, M.D.President, LMS
LMS Dinner Meeting
November 13, 2019
The Opioid Crisis
Insights from the Pharmaceutical Trial
Guest Speaker
Danesh Mazloomdoost, MD
When: November 13, 2019
- 6:00pm Social
- 6:30pm Dinner
- 7:00pm Program
- 8:00pm Complete
Where: Hilary J. Boone Center,
University of Kentucky, 500 Rose Street
Cost: Free to members & their spouses
$30 for non-member guests
Go to lexingtondoctors.org to
register and for more information
Note:Date Change
To WednesdayNov. 13, 2019
Lexington Medical SocietyOpioid Symposium: Perspectives,
Connections, & Strategies for Action
LMS Opioid Symposium
