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Dr. John McAuliffe Medical Director, Sauk Prairie Memorial Hospital

Sharon Boesl, Ph.D., LMFT

Mental Health and Recovery Services Sauk County Department of Human Services

Slides are courtesy of:

The Opioid Epidemic

0 2,000 4,000 6,000 8,000

10,000 12,000 14,000 16,000 18,000

Rx Opioids Heroin

Opioid Pain Relievers Driving U.S. Overdose Epidemic, Heroin Catching Up

Original Data Matt Gladden, CDC

(overdose deaths can involve multiple drugs - not mutually exclusive)

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Epidemiology Wisconsin

p Death certificates p Hospital discharge and emergency

department data p  Prescription Drug Monitoring Program

(PDMP) p Medical Examiner or Coroner data p  Emergency department encounter data p Wisconsin Ambulance Run Data System

Surveillance: Data Sources and Systems

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Wisconsin Age-Adjusted Injury Death Rate, 1999-2013

40

45

50

55

60

65

70

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

27% increase

CDC WISQARS, 9/2/2015

Leading Injury Death Rates, Wisconsin Residents, 1999-2013

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1999

20

00 20

01 20

02 20

03 20

04 20

05 20

06 20

07 20

08 20

09 20

10 20

11 20

12 20

13

Dea

ths

per

10

0,0

00

peo

ple

Year

Falls

Drug Overdose

Motor Vehicle Traffic-related

Age-adjusted, Source: DHS, OHI

5

708 deaths

Wisconsin Unintentional Drug Poisoning, Age-Adjusted Death Rates, 1999-2013 All Races, Both Sexes, All Ages―ICD-10 Codes: X40―X44

2.3 3.0 3.3

4.4 5.0 5.3

6.7

7.9 8.4

7.7 8.1 8.3

9.6 10.1

12.5

0

2

4

6

8

10

12

14

Rat

es p

er 1

00

,00

0

122 deaths

CDC WISQARS: National Center for Injury Prevention and Control, CDC Data Source: NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates.

Number of Drug Overdose Deaths Involving Opioid (morphine-like) Pain Relievers and Other Drugs, Wisconsin, 1999–2014

Source: DHS, OHI 3.5Xincreaseinheroin,from2009(77)to2014(267)

0

50

100

150

200

250

300

350

400

450

1999

20

00

2001

20

02

2003

20

04

2005

20

06

2007

20

08

2009

20

10

2011

20

12

2013

20

14

Opioid pain relievers (T40.2-T40.4) Benzodiazepines (T42.4)

Heroin (T40.1)

Cocaine (T40.5)

6

Source: DHS, OHI 4b=All Prescription Opioid Analgesics, except Methadone

Overdose Deaths by Age Group and Opioid Type, 2010-2014 (Any Mentions)

<15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

OPIOIDLSMTD(4b) 8 18 83 142 149 150 167 226 230 189 89 73

HEROIN(5) 17 150 194 140 115 74 70 72 40 28 7

0

50

100

150

200

250

Five

Yea

r (t

otal

cou

nt)

Rate of Deliveries With Maternal Opioid Use, Rate of Neonatal Abstinence Syndrome, Wisconsin, 2009–2014

2009 2010 2011 2012 2013 2014 Maternal Opioid Use 335 506 719 842 1001 1041

NAS N=227 305 384 398 540 508

12 Source: DHS 12

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p Chronic untreated heroin use is associated with: n  Risk of fetal growth restriction n  Abruptio plancentae n  Fetal death n  Preterm labor n  Exposure to episodes of withdrawal

n  The lifestyle issues associated with illicit drug use also create risk for the mother and developing fetus.

Effects on Pregnancy

Neonatal Abstinence Syndrome

Infants with neonatal abstinence syndrome may have uncoordinated sucking reflexes leading to poor feeding, become irritable, and produce a high-pitched cry. Long term outcome study of infants with in utero exposure to opioid exposure are limited. From: Committee Opinion, The American College of Obstetricians and Gynecologists (May 2012).

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Actions to Prevent Opioid Harm and Abuse

Reversal Naloxone Access

Policies Supporting all sectors

Education •  Prescriber

education •  Community

education •  Naloxone

access

Tracking and Monitoring

•  Prescription Drug Monitoring System (PDMP)

•  Surveillance

Enforcement •  Identification verification at

pharmacies •  Law enforcement training

on prescription drug misuse and diversion

Medication Disposal •  Keeping medications safe at home •  Proper medication disposal guidelines

consistent with FDA standards •  Community take-back programs

Treatment Options •  Treatment Centers •  Outpatient and residential

treatment at state-funded treatment providers

Our local project: Sauk County Medication Assisted Treatment

Grant

The grant’s goals: 1.  Increase medication assisted treatment as an option for sobriety and increase the

number of providers in each area to provide better access to treatment.

2. Utilize the C.A.R.E. concept/process (Community Activated Recovery Enhancement) as a model in four (4) strategic locations and include community stakeholders in all aspects of developing a coordinated response to this alarming health issue. 3. Utilize all existing funding resources FIRST for treatments including individual’s existing health care funding such as private insurance/Medical Assistance. 4. With oversight and State approval some funds (about 25%) are designated for gap populations–individuals who are particularly vulnerable and in need of services and community support (individuals transitioning from incarceration, pregnant, individuals with Hepatitis C, and uninsured individuals.)

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FDA approved medications n  Buprenorphine products (Suboxone and Subutex) n  Naltrexone (Vivitrol) n  Methadone

Medication-Assisted Treatment

Schedule III narcotic medication for the maintenance treatment of opioid dependence

n  Reduces cravings and withdrawal symptoms n  Available at OTPs and from DATA waived

physicians

Buprenorphine Products (Suboxone and Subutex)

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A prescription injectable medication containing naltrexone

n  Administered once a month to prevent relapse to opioid dependence after detox

n  Must stop all opiates 7-10 days prior to injection

Naltrexone (Vivitrol)

p  Provides comprehensive services n  Medication n  Counseling n  Case management n  Recovery supports

p Uses many paths to recovery n  Medical intervention n  Professional treatment n  Mutual support groups n  Peer supports n  Family supports n  Faith supports

Medication-Assisted Treatment (MAT)

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p Develops diversion practices and policies p Develops Recovery-Oriented Systems of Care

(ROSC), an integrated care model:

Medication-Assisted Treatment (MAT)

--A framework to guide system transformation --A value-driven approach to structuring behavioral health systems --A network of clinical and non-clinical and supports --An initiative to find service gaps and community needs to transform

the community into a stronger support for life-long recovery

William White on Recovery Oriented Systems of Care (ROSC)

“This movement represents a shift away from crisis-oriented, professionally directed, acute-care approach with it’s emphasis on isolated treatment episodes, to a recovery management approach that provides long-term supports and recognizes the many pathways to healing.”

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p Screen and intervene in health care facilities p  Establish relationships with natural supports

to promote early identification p Offer pre-treatment peer support groups p Use peers to welcome consumers p Offer peer mentors at first contact p Build linkages between levels of care through

peer-based recovery support services

Assertive Outreach and Engagement

State Funded

n  Medication-assisted treatment training for prescribers and providers

n  Heroin Opiate Prevention and Education (H.O.P.E.) Programs

Federally Funded (Grants) n  Community Activated

Recovery Enhancement (C.A.R.E.) Project

n  Prescription Drug Monitoring Program enhancement

n  Prevention grants focus on prescription drugs

DHS Efforts

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Programs Offering Methadone for Opioid Addiction

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3

4

67 8 9

10 11

4

12 1314

1516

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EauClaireMetroTreatmentCenter,EauClaire,715-834-1078

WisconsinComprehensiveTreatmentCenters,Wausau,715-845-3637

WisconsinComprehensiveTreatmentCenters,GreenBay,920-337-6740

WisconsinComprehensiveTreatmentCenters,Appleton(ValleyHealthServices),920-733-4443

AddictionMedicalSolutions,Oshkosh,920-232-2332

GundersonLutheranHealthSystems,LaCrosse,608-775-3395

PremierCareofWisconsin,FondduLac,920-926-0101

WisconsinComprehensiveTreatmentCenters,Sheboygan,920-458-6527

WisconsinComprehensiveTreatmentCenters,Madison(BadgerRoad),608-250-2512

WisconsinComprehensiveTreatmentCenters,Madison(MadisonHealthServices-WorldDairyExpoDrive),608-242-0220

WisconsinComprehensiveTreatmentCenters,Waukesha,262-549-6600

WisconsinComprehensiveTreatmentCenters,WestMilwaukee,414-672-3801

WisconsinComprehensiveTreatmentCenters,Milwaukee(RiverShores),414-967-7012

WisconsinComprehensiveTreatmentCenters,Milwaukee(10th Street),414-744-5370

WisconsinComprehensiveTreatmentCenters,Racine,262-598-1392

WisconsinComprehensiveTreatmentCenters,Beloit,608-361-7200

H.O.P.E.ProjectNorthCentralRegionOpioidConsortiumHeadquarters:Woodruff715-358-1221

Opioid Treatment Programs (OTP)

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AddictionMedicalSolutions,Onalaska,608-783-0506

Flipoverformoreoptionsdhs.wisconsin.gov/opioids/treatment.htm November2015

Newly Funded Opioid Treatment Programs

Opioid Treatment Services

Theseprojectsarefundedbyeitherstateorfederaldollarsandprovidearangeofservicestohelpindividualsovercomeanaddictiontoopioids.Theseprogramsdonotprovidemethadonemaintenancetreatment.

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H.O.P.E.Project:NorthLakesCommunityClinicHeadquarters:Ashland,715-682-5207

H.O.P.E.Project:NorthCentralRegionOpioidConsortiumHeadquarters:Woodruff,715-358-1221

H.O.P.E.Project:Libertas/PreveaHealthCollaborativeHeadquarters:Marinette,715-735-0095

C.A.R.E.ProjectHeadquarters:Baraboo,608-355-4200

dhs.wisconsin.gov/opioids/treatment.htm November2015

Medication-Assisted Treatment

Northern tier of Wisconsin: n  Provide medication-assisted treatment to the

underserved and high-need areas in Wisconsin n  Provide residential detoxification and

stabilization services n  Reduce the rate of relapse and number of

deaths n  Reduce the number of infants born to untreated

opioid addicted women n  Create relationships with community providers

to improve treatment availability

H.O.P.E. Programs

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Sauk, Columbia, Richland counties: n  Replicates a program originated by St. Vincent

DePaul in Prairie Du Sac n  Involves community stakeholders committees n  Expands the provision of medication-assisted

treatment n  Employs Community Recovery Specialists

Employs dually credentialed clinician for assessments and treatment planning

n  Adds a mobile nurse to support individuals who choose to detox at home

n  Contracts with providers for treatment services, detox, outpatient, inpatient residential, etc.

C.A.R.E. Project

Elizabeth Collier State Opioid Treatment Authority Elizabeth.Collier@dhs.wisconsin.gov 608-267-7707 Andrea Jacobson Substance Abuse Treatment Coordinator andrea.jacobson@dhs.wisconsin.gov 608-261-0652

For More Information

dhs.wisconsin.gov/opioids/index.htm